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Short-Term Outcomes and Risk Factors for Requiring Extracorporeal Life Support After Norwood Operation: A Single Center Retrospective Study 

Presented By:

Asaad G. Beshish, MD (1); Alan Amedi, BS (2); Ashley Harriott, BA (2); Shayli Patel, BA (2); Sean Evans, MD (2); Amy Scheel, MD (2); Yijin Xiang, MPH (3); Subhadra Shashidharan, MD (4); Vamsi Yarlagadda, MD (5); Alaa Aljiffry, 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; 5. Division of Pediatric Cardiology, Stanford University School of Medicine, Lucile Packard Children's Hospital.

beshisha@kidsheart.com

Overview:

Background: Patients requiring extracorporeal life support (ECLS) support after a Norwood
operation constitutes an extremely high-risk group. Data regarding short-term outcomes, functional status, and risk factors for the requirement for ECLS post-Norwood are limited. We retrospectively described short-term outcomes, functional status, and assessed risk factors for requiring ECLS support after a Norwood operation in a high-volume center.

Methods: Retrospective single-center study at an academic quaternary children’s hospital. All patients who required ECLS after Norwood operation between January/2010 – December/2020 were included. Analysis was performed using appropriate statistics with significance level set at p = 0.05. 

Results: During the study period, 269 patients underwent a Norwood procedure of which 65 (24%) required post-Norwood ECLS. Of the patients who required post-Norwood ECLS, 27 (42.5%) survived to hospital discharge. Mean functional status score (FSS) score on discharge increased from 6.0 to 8.48 (mean change 2.36, 95% CI 2.02, 2.70, p <0.0001). This change was primary in feeding (p <0.0001) and respiratory domains p=0.017). Of the survivors 7 (26%) developed new morbidity and 2 (7%) developed unfavorable outcomes. 

In a logistic regression analysis patients with moderate – severe univentricular dysfunction on the pre-Norwood transthoracic echocardiogram (TTE) (OR 9.80, 95% CI 4.47, 21.52), m-BTT shunt as source of pulmonary blood flow (OR 2.0, 95% CI 1.12, 3.57), moderate to severe atrioventricular valve regurgitation (AVVR) (OR 4.90, 2.14, 11.23) and moderate-severe ventricular dysfunction (OR 3.20, 95% CI 1.22, 8.41) on the intraoperative transesophageal echocardiogram (TEE), delayed sternal closure (OR 3.8, 95% CI 1.88, 7.69), post-Norwood vasoactive inotropic score (VIS) score in the first 24 hours (OR 1.30 (95% CI 1.15, 1.47), and hours 24 – 48 (OR 1.54, 95% CI 1.34, 1.76), post-Norwood inhaled nitric oxide (iNO) on arrival to CICU, Cath interventions (OR 10.8, 95% CI 5.68, 20.52) had higher odds of post-Norwood ECLS requirement (p<0.05). Risk factors with significant univariable results were included in the final model for multivariable regression. Significance remained in all risk factors, except for moderate – severe ventricular dysfunction in the intraoperative TEE, post-Norwood iNO on arrival to CICU, and VIS Score for first 24 hours (Table 3).

Conclusions: Patients requiring ECLS post-Norwood procedure have a 43% survival. Of the survivors, 26% developed new morbidity and 7% developed unfavorable outcomes.  Patients with worse univentricular function in the pre-Norwood TTE and intraoperative TEE, delayed sternal closure, required iNO post-Norwood on arrival to CICU, higher post-Norwood VIS scores, and required post-Norwood Cath interventions have higher odds of requiring post-Norwood ECLS support.