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24. Influence of surgical strategies on outcome after Norwood procedure
Massimo Griselli, Simon P Mcguirk, Oliver Stümper, Andrew JB Clarke, Paul Miller, Rami Dhillon, John GC Wright, Joseph V De Giovanni, David J Barron, William J Brawn; Birmingham, United Kingdom

Objective
This study sought to identify how the evolution of surgical strategies influenced outcome after Norwood procedure (NP).
Methods
From 1992 to 2004, 367 patients underwent NP at a median age of 4 days (IQR, 3-7 days). Most patients had a right ventricular dependent systemic circulation (n=334, 91%).
Three surgical strategies were identified based on the arch reconstruction and source of pulmonary blood flow (PBF). In Group A (n=148), the arch was refashioned without extra material. In Group B (n=145) and C (n=78), the arch was reconstructed with a pulmonary artery homograft patch. In Group A and B, PBF was supplied by a modified Blalock-Taussig shunt (MBTS). In Group C, PBF was supplied by a right ventricle to pulmonary artery (RV-PA) conduit.
Early mortality, actuarial survival and freedom from arch reintervention or central pulmonary artery (CPA) patch augmentation were analysed using univariable and multivariable analyses.
Results
Early mortality for the entire series was 28% (n=102). There were 31 inter-stage deaths. Actuarial survival was 62±3% at 6 months. Early mortality was lower in Group C (15%) than Group A (31%) or B (31%; p<0.05). Early mortality was 2.6 times lower in Group C than Group A or B on multivariable analysis (RR 0.38; 95% CI, 0.18-0.78). Actuarial survival at 6 months was also better in Group C (78±5%) than Group A (59±5%) or B (58±4%; p<0.05). Actuarial survival in Group C was 2 times better than Group A or B on multivariable analysis (OR 0.51; 95% CI, 0.30-0.86).
Fifty-three patients (14%) had arch reintervention after NP. Freedom from arch reintervention was 76%±3% at 1 year. On univariable analysis, there was no difference between Group A and Group B or C (p=0.71). There was no difference whether the aortic back wall was left in continuity (16%) or the coarctation resected completely (14%; p=0.78).
One hundred patients (27%) required subsequent CPA patch augmentation at stage II. Freedom from CPA patch augmentation was 61%±3% at 1 year, and was lower in Group C (3±3%) than Group A (80±4%) or B (72±5%; p<0.05). Group C was more likely to have CPA patch augmentation than Group A or B on multivariable analysis (OR 7.41; 95% CI, 4.73-11.63).
Conclusions
Our experience has shown a clear improvement in survival following the introduction of the NP with RV-PA conduit. However, a greater proportion required subsequent CPA patch augmentation. The type of arch reconstruction did not affect the incidence of subsequent arch reintervention.

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