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Short-Term Outcomes, Risk Factors for Mortality and Functional Status in Univentricular Patients After Norwood Operation: A Single Center Retrospective Study 

Presented By:

Alaa Aljiffry, MD (1); Amy Scheel, MD (2); Sean Evans, MD (2); Shayli Patel, BA (2); Ashley Harriott, BA (2); Alan Amedi, BS (2); Yijin Xiang, MPH (3); Subhadra Shashidharan, MD (4); Asaad G. Beshish, MD (1)

1. Division of Pediatric Cardiology, Emory University School of Medicine, Children’s Healthcare of Atlanta; 2. Emory University School of Medicine; 3. Biostatistician, Department of Pediatrics, Emory University School of Medicine; 4. Division of Cardiothoracic Surgery, Emory University School of Medicine, Children’s Healthcare of Atlanta

aljiffrya@kidsheart.com

Overview:

Background: Infants with univentricular physiology require multiple surgical palliations, the first of which is the Norwood operation (NO) (Stage I palliation). Despite advances in surgical and medical care over the last two decades, the interstage period mortality after NO has been described as high as 10 – 15%. This study aimed to evaluate the outcomes and examine risk factors associated with mortality after NO at a high-volume center.

Methods: Single-center retrospective study at an academic children’s hospital. All patients who underwent NO between January/2010 – December/2020 were included. Analysis was performed using appropriate statistics with a significance level set at p = 0.05. 

Results: During the study period, 269 patients underwent a NO, of which 213 (79.2%) survived to hospital discharge. Non-survivors had longer cardiopulmonary bypass (CPB) time, post-Norwood iNO requirement, delayed sternal closure, higher vasoactive inotropic score (VIS), required post-operative Cath interventions, and extracorporeal life support (ECLS) (p<0.05). 

In a logistic regression analysis, moderate – severe atrioventricular valve regurgitation (AVVR) (OR 2.6, 95% CI 1.11, 6.09) on the intraoperative transesophageal echocardiogram (TEE), requirement of iNO post-Norwood (OR 2.63, 95% CI 1.23, 5.62), delayed sternal closure (OR 2.94, 95% CI 1.44, 5.99), post-Norwood Cath intervention (OR 10.48, 95% CI 5.3,20.72), and post-Norwood ECLS requirement (OR 14.54, 95% CI 7.29,29.02) had higher odds of operative mortality (p<0.05). Risk factors with significant univariable results were included in the final model for multivariable regression. Significance only remained for postoperative ECLS and cardiac catheterization requirement.

We assessed functional status of survivors using functional status scale (FSS) and found that mean FSS score on discharge increased from 6.0 on admission to 8.04 (mean change 2.21, 95% CI 2.06, 2.36, p <0.0001). This was primarily due to changes in feeding (p <0.0001) and respiratory domains (p=0.001). Of the survivors, 26 (12.3%) developed new morbidity, and 9 (4.2%) developed unfavorable outcomes.

Conclusions: Patients with worse univentricular function and AVV regurgitation in the intraoperative TEE, delayed sternal closure, Post Norwood iNO requirement, post-Norwood Catheterization and ECLS requirements have higher odds of mortality. Patients requiring post-Norwood ECLS have 14.5 higher odds of mortality. Of the survivors, 12.3% developed new morbidity, and 4.3% developed unfavorable outcomes.