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Open Access Research article

One size does not fit all: the influence of age at surgery on outcomes following Norwood operation

Tara Karamlou1*, Kristen Sexson2, Andrea Parrish1, Karl F Welke3, D Michael McMullan4, Lester Permut4 and Gordon Cohen1

Author Affiliations

1 Division of Pediatric Cardiac Surgery, Benioff Children’s Hospital, University of California, San Francisco, 513 Parnassus Avenue, Suite S-549, California, CA 94143, USA

2 Division of Pediatric Cardiology, Texas Children’s Hospital, Houston, TX, USA

3 Division of Pediatric Cardiac Surgery, Children’s Hospital of Illinois, Peoria, Il, USA

4 Section of Pediatric Cardiothoracic Surgery, University of Washington School of Medicine and Seattle Children’s Hospital, Seattle, WA, USA

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Journal of Cardiothoracic Surgery 2014, 9:100  doi:10.1186/1749-8090-9-100

Published: 14 June 2014

Abstract

Background

Given our large catchment area that often results in later presentation age, we sought to understand our institutional outcomes for the Norwood operation in the context of published data. Specifically, we studied whether operative and late death post-Norwood are dependent on age at operation.

Methods

Retrospective review of 105 consecutive infants undergoing Norwood (2004–2011) at our institution. Patients were divided into those undergoing Norwood ≤ 7 days of age (N = 43; 41%) and those undergoing Norwood > 7 days of age (N = 63; 59%). Operative mortality (≥30 days), interstage mortality (between Norwood and superior bidirectional Glenn), STS-mortality (operative death + in-hospital death), and late mortality, occurring any time following hospital discharge were compared among groups. Multivariable factors for mortality at each time-point were compared using logistic regression models.

Results

Underlying diagnosis was HLHS in 67 (64%) with the remainder (N = 38; 36%) being other single ventricle variants. Median age at surgery was 8 days (range 1–63 days) and mean weight at surgery was 3.2 ± 0.6 kg. Pulmonary blood flow was provided by a right ventricle-pulmonary artery conduit in 94% (N = 99). Overall operative survival was 92%, with 73% (N = 66) undergoing bidirectional Glenn. Median age was higher for operative survivors compared to non-survivors (12 days vs. 5 days; P = 0.036), with operative mortality higher for infants ≤7 days at Norwood compared to infants >7 days at Norwood (14% vs. 3%; P = 0.04). After censoring for in-hospital death, age ≤ 7 days was also associated with increased risk for late death (26% vs. 5%; P = 0.005).

Conclusions

In contrast to other institutional series, infants at our center undergoing Norwood operation at an earlier age have worse outcomes. Adoption of published practice patterns could lead to different local outcomes because of intangible center-specific effects, underscoring the principle that results from one institution may not be generalizable to others. Targeted center-specific internal review, if possible, should precede externally recommended changes in practice.

Keywords:
Norwood; Single ventricle; Outcomes; Risk-factors; Congenital heart disease