Early Outcomes of the Norwood Procedure in a Reference Center in Brazil

Bezerra, Rodrigo Freire; Pacheco, Juliana Torres; Franchi, Sônia Meiken; Fittaroni, Rosangela Belbuche; Baumgratz, José Francisco; Castro, Rodrigo Moreira; Silva, Luciana da Fonseca da; Silva, José Pedro da

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Original Article • Arq. Bras. Cardiol. 119 (2) • Aug 2022 • https://doi.org/10.36660/abc.20201226 copy

Early Outcomes of the Norwood Procedure in a Reference Center in Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background

Only two papers have addressed the early outcomes of patients with hypoplastic left heart syndrome (HLHS) undergoing the Norwood operation, in Brazil.

Objectives

We evaluated patients with HLHS undergoing the first-stage Norwood operation in order to identify the predictive factors for early (within the first 30 days after surgery) and intermediate (from early survival up to the Glenn procedure) mortality.

Methods

Patients with HLHS undergoing the stage I Norwood procedure from January 2016 through April 2019, in our service, were enrolled. Demographic, anatomical, and surgical data were analyzed. Endpoints were early mortality (within the first 30 days after surgery), intermediate mortality (from early survival up to the Glenn procedure) and the need for postoperative ECMO support. Univariate and multivariate analyses were performed, and odds ratios, with 95% confidence intervals, were calculated. A p-value <0.05 was considered statistically significant.

Results

A total of 80 patients with HLHS underwent the stage I Norwood procedure. The 30-day survival rate was 91.3% and the intermediate survival rate 81.3%. Fourteen patients (17.5%) required ECMO support. Lower weight (p=0.033), aortic stenosis (vs aortic atresia; p=0.036), and the need for postoperative ECMO support (p=0.009) were independent predictive factors for 30-day mortality. Mitral valve stenosis (vs mitral valve atresia; p=0.041) was an independent predictive factor for intermediate mortality.

Conclusion

The present study includes the largest Brazilian cohort of patients with HLHS undergoing the stage I Norwood procedure in the recent era. Our survival rates were comparable to the highest survival rates reported globally. Low body weight, aortic valve stenosis, and the need for postoperative ECMO support were independent predictors for 30-day mortality. Mitral valve stenosis was the only independent predictive factor for intermediate mortality.

Hypoplastic Left Heart Syndrome; Norwood Procedures; Extracorporeal Membrane Oxygenation; Mortality

Sex (males)	Survivors	Nonsurvivors (30-day)	p-value
	46/73 (63.0%)	5/7 (71.4%)	1.000
Weight (g)	Survivors	Nonsurvivors (30-day)	p-value
	3115 (2820-3440)	2740 (2500-2990)	0.0257
Age (days)	Survivors	Nonsurvivors (30-day)	p-value
	3.0 (1.0-147.0)	3.0 (2.0-5.0)	0.1893

ASD
Area (mm²)	Survivors	Nonsurvivors (30-day)	p-value
Total estimated ASD area	10.95 (5.93-18.10)	8.7 (7.10-20.40)	0.7714
Heart valves (LEFT)
Mitral valve	Survivors	Nonsurvivors (30-day)	p-value
normal	1/72 (1.4%)	0/7 (0.0%)	0.2187
stenosis	37/72 (51.4%)	6/7 (85.7%)
atresia	34/72 (47.2%)	1/7 (14.3%)
Aortic valve	Survivors	Nonsurvivors (30-day)	p-value
normal	2/73 (2.7%)	0/7 (0.0%)	0.2508
stenosis	20/73 (27.4%)	4/7 (57.1%)
atresia	51/73 (69.9%)	3/7 (42.9%)
Subgroups	Survivors	Nonsurvivors (30-day)	p-value
MS/AS	17/73 (23.3%)	4/7 (57.1%)	0.3267
MS/AA	19/73 (26.0%)	2/7 (28.6%)
MA/AS	2/73 (2.7%)	0/7 (0.0%)
MA/AA	32/73 (43.8%)	1/7 (14.3%)
other	3/73 (4.1%)	0/7 (0.0%)
Aorta
Ascending aorta	Survivors	Nonsurvivors (30-day)	p-value
size (mm)	2.80 (2.00-4.30)	2.00 (2.00-6.20)	0.6612
patent ductus arteriosus	Survivors	Nonsurvivors (30-day)	p-value
size (mm)	5.75 (5.00-6.50)	6.70 (4.50-7.30)	0.5569

Shunt diameter (mm)	Survivors	Nonsurvivors (30-day)	p-value
3.5	1/41 (2.4%)	0/3 (0.0%)	0.9403
4.0	11/41 (26.8%)	1/3 (33.3%)
5.0	29/41 (70.7%)	2/3 (66.7%)
Banding	Survivors	Nonsurvivors (30-day)	p-value
patients undergoing shunt banding	11/32 (34.4%)	0/2 (0%)	0.3134
Surgery times	Survivors	Nonsurvivors (30-day)	p-value
CPB (min)	185 (170-210)	205 (180-240)	0.2202
Cross-clamp (min)	76 (70-80)	77 (59-82)	0.7057

	univariate		multivariate

	OR (95%CI)	p-value	OR (95%CI)	p-value
Demographics
Sex (for male)	1.524 (0.432-5.383)	0.513	-	-
Weight (per g)	1.000 (0.998-1.001)	0.515	-	-
Age (per day)	0.860 (0.606-1.220)	0.397	-	-
Anatomy
Total estimated ASD area (per mm²)	0.982 (0.944-1.021)	0.354	-	-
Mitral valve (atresia vs. stenosis)	0.905 (0.282-2.909)	0.867	-	-
Aortic valve (atresia vs. stenosis)	1.791 (0.451-7.112)	0.408	-	-
Asc Ao size (per mm)	0.907 (0.635-1.295)	0.590	-	-
Surgery
CPB (per min)	1.006 (0.996-1.016)	0.248	1.006 (0.996-1.016)	0.248
Cross-clamp (per min)	0.997 (0.944-1.054)	0.922	-	-

	univariate		multivariate

	OR (95%CI)	p-value	OR (95%CI)	p-value
Demographics
Sex (for males)	1.467 (0.266-8.091)	0.660	-	-
Weight (per g)	0.998 (0.996-1.000)	0.056	0.997 (0.995-1.000)	0.033
Age (per day)	0.734 (0.382-1.413)	0.355	-	-
Anatomy
total estimated ASD area (per mm²)	1.010 (0.983-1.037)	0.465	-	-
mitral valve (atresia vs. stenosis)	0.181 (0.021-1.585)	0.123	0.491 (0.024-10.089)	0.645
aortic valve (atresia vs. stenosis)	0.294 (0.060-1.433)	0.130	0.090 (0.009-0.857)	0.036
Asc Ao size (per mm)	0.981 (0.620-1.552)	0.935	-	-
Surgery
CPB (per min)	1.010 (0.999-1.021)	0.089	1.018 (0.992-1.044)	0.173
Cross-clamp (per min)	0.952 (0.874-1.037)	0.260	-	-
ECMO	8.400 (1.631-43.256)	0.011	20.975 (2.116-207.886)	0.009

	univariate		multivariate

	OR (95%CI)	p-value	OR (95%CI)	p-value
Demographics
Sex (for males)	1.719 (0.493-5.991)	0.395	-	-
Weight (per g)	1.000 (0.998-1.001)	0.511	-	-
Age (per day)	1.008 (0.986-1.031)	0.457	-	-
Anatomy
Total estimated ASD area (per mm²)	1.010 (0.989-1.031)	0.354	-	-
Mitral valve (atresia vs. stenosis)	0.242 (0.062-0.942)	0.041	0.242 (0.062-0.942)	0.041
Aortic valve (atresia vs. stenosis)	0.422 (0.133-1.343)	0.144	0.357 (0.059-2.174)	0.264
Asc Ao size (per mm)	1.003 (0.723-1.392)	0.984	-	-
Surgery
CPB (per min)	1.008 (0.998-1.018)	0.131	1.017 (0.998-1.037)	0.080
Cross-clamp (per min)	0.992 (0.936-1.051)	0.785	-	-
ECMO	3.111 (0.862-11.231)	0.083	3.011 (0.623-14.542)	0.170

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