Norwood operation versus comprehensive stage II after bilateral pulmonary artery banding palliation for infants with critical left heart obstruction

J Thorac Cardiovasc Surg. 2023 Sep;166(3):943-954.e1. doi: 10.1016/j.jtcvs.2023.01.013. Epub 2023 Jan 23.

Abstract

Objective: To determine patient characteristics and outcomes after Norwood versus comprehensive stage II (COMPSII) for infants with critical left heart obstruction who had prior hybrid palliation (bilateral pulmonary artery banding ± ductal stent).

Methods: From 23 Congenital Heart Surgeons' Society institutions (2005-2020), 138 infants underwent hybrid palliation followed by either Norwood (n = 73, 53%) or COMPSII (n = 65). Baseline characteristics were compared between Norwood and COMPSII groups. Parametric hazard model with competing risk methodology was used to determine risk and factors associated with outcomes of Fontan, transplantation, or death.

Results: Infants who underwent Norwood versus COMPSII had a higher prevalence of prematurity (26% vs 14%, P = .08), lower birth weight (median 2.8 vs 3.2 kg, P < .01) and less frequent ductal stenting (37% vs 99%; P < .01). Norwood was performed at a median age of 44 days and median weight of 3.5 kg, versus COMPSII at 162 days and 6.0 kg (both P < .01). Median follow-up was 6.5 years. At 5 years after Norwood and COMPSII, respectively; 50% versus 68% had Fontan (P = .16), 3% versus 5% had transplantation (P = .70), 40% versus 15% died (P = .10), and 7% versus 11% are alive without transition, respectively. For factors associated with either mortality or Fontan, only preoperative mechanical ventilation occurred more frequently in the Norwood group.

Conclusions: Higher prevalence of prematurity, lower birth weight, and other patient-related characteristics in the Norwood versus COMPSII groups may influence differences in outcomes that were not statistically significant for this limited risk-adjusted cohort. The clinical decision regarding Norwood versus COMPSII after initial hybrid palliation remains challenging.

Keywords: Norwood; comprehensive stage II; critical left heart obstruction; hybrid palliation; hypoplastic left heart syndrome; pulmonary artery banding; univentricular palliation.

MeSH terms

  • Birth Weight
  • Heart Block
  • Humans
  • Hypoplastic Left Heart Syndrome* / complications
  • Hypoplastic Left Heart Syndrome* / surgery
  • Infant
  • Norwood Procedures*
  • Palliative Care / methods
  • Pulmonary Artery / diagnostic imaging
  • Pulmonary Artery / surgery
  • Retrospective Studies
  • Risk Factors
  • Treatment Outcome