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J Thorac Cardiovasc Surg. 2008 Oct;136(4):993-7, 997.e1-2. doi: 10.1016/j.jtcvs.2007.12.091. Epub 2008 Aug 15.

Measurement of technical performance in surgery for congenital heart disease: the stage I Norwood procedure.

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Department of Cardiac Surgery, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts 02115, USA.



No method of measuring technical performance exists for the stage I Norwood procedure. Hospital mortality is usually used as a surrogate for technical performance, but evidence is lacking to support this concept. A technical score was designed by expert consensus.


The technical score included the following steps: (1) Stage I was divided into subprocedures according to anatomic areas where an intervention is performed. (2) For each subprocedure, three score categories (optimal, adequate, and inadequate) were defined on the basis of echocardiography, catheterization, and/or clinical data. (3) Subprocedures were analyzed for the whole group and by surgeon. (4) Overall repair was also scored: optimal if all attempted subprocedures were optimal, inadequate if any was inadequate, and adequate for everything in between. (5) All patients undergoing the stage I procedure from January 2004 to December 2006 were retrospectively studied.


One hundred ten patients were included (operated on by six surgeons), and 4 were excluded for lack of reliable postoperative data. Most subprocedures were scored as optimal. Subprocedures with the largest inadequate scores were distal arch reconstruction in 7 (6%) patients and aortopulmonary shunt in 3 (5%). No statistical differences were found among surgeons either by subprocedure or by overall outcome, although individual sample sizes were small. The overall score correlated with length of stay, extracorporeal membrane oxygenator support, and hospital mortality.


Technical performance can be measured after the stage I procedure, and performance score correlates with early outcome. This score may also be useful as a self-assessment tool.

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