Intermediate-term mortality and cardiac transplantation in infants with single-ventricle lesions: Risk factors and their interaction with shunt type

• Type of Material: Article
• Authors: James S. Tweddell, Medical College of Wisconsin; Lynn A. Sleeper, New England Research Institutes; Richard G. Ohye, University of Michigan; Ismee A. Williams, Columbia University; Lynn Mahony, University of Texas Southwestern Medical Center; Christian Pizarro, Alfred I. duPont Hospital for Children; Victoria L. Pemberton, National Heart, Lung, and Blood Institute; Peter C. Frommelt, Medical College of Wisconsin; Scott M. Bradley, Medical University of South Carolina; James F. Cnota, Cincinnati Children's Hospital Medical Center; Jennifer Hirsch, University of Michigan; Paul Kirshbom, Emory University; Jennifer S. Li, Duke University; Nancy Pike, Children's Hospital Los Angeles; Michael Puchalski, Primary Children's Medical Center; Chitra Ravishankar, Children's Hospital of Philadelphia; Jeffrey P. Jacobs, Congenital Heart Institute of Florida; Peter C. Laussen, Children's Hospital Boston; Briwn W. McCrindle, University of Toronto; William Mahle, Emory University; Kirk Kanter, Emory University
• Language: English
• Date: 2012-01-01
• Publisher: Elsevier
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: Copyright © 2012 by The American Association for Thoracic Surgery.
• License: Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1016/j.jtcvs.2012.01.016
• Title of Journal or Parent Work: Journal of Thoracic and Cardiovascular Surgery
• ISSN: 0022-5223
• Volume: 144
• Issue: 1
• Start Page: 152
• End Page: 159
• Grant/Funding Information: Supported by U01 grants from the National Heart, Lung, and Blood Institute (HL068269, HL068270, HL068279, HL068281, HL068285, HL068292, HL068290, HL068288, HL085057).
• Keywords: Male; Infant, Newborn; Child, Preschool; Algorithms; Gestational Age; Infant; Treatment Outcome; Humans; Hypoplastic Left Heart Syndrome; Norwood Procedures; Heart Transplantation; Echocardiography, Doppler; Female; Blalock-Taussig Procedure; Social Class; Infant, Premature; Risk Factors
• Research Categories: Health Sciences, Medicine and Surgery

Abstract

Objective: The study objective was to identify factors associated with death and cardiac transplantation in infants undergoing the Norwood procedure and to determine differences in associations that might favor the modified Blalock-Taussig shunt or a right ventricle-to-pulmonary artery shunt. Methods: We used competing risks methodology to analyze death without transplantation, cardiac transplantation, and survival without transplantation. Parametric time-to-event modeling and bootstrapping were used to identify independent predictors. Results: Data from 549 subjects (follow-up, 2.7 ± 0.9 years) were analyzed. Mortality risk was characterized by early and constant phases; transplant was characterized by only a constant phase. Early phase factors associated with death included lower socioeconomic status (P = .01), obstructed pulmonary venous return (P < .001), smaller ascending aorta (P = .02), and anatomic subtype. Constant phase factors associated with death included genetic syndrome (P < .001) and lower gestational age (P < .001). The right ventricle-to-pulmonary artery shunt demonstrated better survival in the 51% of subjects who were full term with aortic atresia (P < .001). The modified Blalock-Taussig shunt was better among the 4% of subjects who were preterm with a patent aortic valve (P = .003). Lower pre-Norwood right ventricular fractional area change, pre-Norwood surgery, and anatomy other than hypoplastic left heart syndrome were independently associated with transplantation (all P < .03), but shunt type was not (P = .43). Conclusions: Independent risk factors for intermediate-term mortality include lower socioeconomic status, anatomy, genetic syndrome, and lower gestational age. Term infants with aortic atresia benefited from a right ventricle-to-pulmonary artery shunt, and preterm infants with a patent aortic valve benefited from a modified Blalock-Taussig shunt. Right ventricular function and anatomy, but not shunt type, were associated with transplantation.