129. Timing of Reintervention is Significantly Associated with In-Hospital Mortality following the Norwood Operation

Objective: Outcomes following the Norwood operation are influenced by many factors. We assessed the impact of timing of unplanned reintervention (RI) on in-hospital mortality after the Norwood operation.

Methods: Clinical and echocardiographic data from all patients who underwent the Norwood operation from 01/1997-11/2017 at a single institution were retrospectively reviewed. Patients were included in the analysis if they (1) required an in-hospital unplanned surgical or catheter-based RI on one or more subcomponent areas repaired at the index surgery (excluding planned staged procedures) and (2) survived to the reintervention. Late RI was defined as any in-hospital RI performed later than two days after the initial Norwood operation. The outcome of interest was in-hospital mortality or transplant. Associations between timing of RI and the outcome were assessed using logistic regression, adjusting for age, prematurity, presence of non-cardiac anomalies or genetic syndromes, and various preoperative- (including mechanical ventilation, renal or hepatic failure, cardiopulmonary resuscitation or shock, mechanical circulatory support, stroke, and sepsis or necrotizing enterocolitis) and procedure-specific risk factors (ascending aorta <2 mm, at least moderate atrioventricular valve regurgitation, aortic atresia, intact atrial septum or obstructed pulmonary venous return, and previous intervention).

Results: Of 500 patients who underwent the Norwood operation, 67 (13.4%) required an in-hospital RI. In this cohort, median age at surgery was 4 days (interquartile range [IQR] 3-7 days), 12 (17.9%) were premature, 12 (17.9%) had noncardiac anomalies or genetic syndromes, 20 (29.9%) had at least one major preoperative risk factor, and 50 (74.6%) had at least one procedural risk factor. Median time to reintervention was 3 postoperative days (IQR 1-7 days), and the outcome of interest was observed in 27 (40.3%) patients. Among those who underwent RI within two postoperative days, there were 2 (14.3%) deaths/transplants. In contrast, there were 25 (47.2%) in-hospital deaths or transplants among patients who required a reintervention at postoperative day 3 and beyond. On univariable analysis, late RI (RI ≥ 3 days) was significantly associated with in-hospital mortality or transplant (odds ratio [OR] 5.4, 95% confidence interval [CI] 1.1-26, p=0.039). This finding was robust (OR 6.4, 95% CI 1.2-33, p=0.027) on multivariable analysis as well (Table).

Conclusions: For patients requiring in-hospital unplanned reinterventions for residual lesions following the Norwood operation, early reintervention, ideally within two postoperative days, may improve transplant-free survival to hospital discharge.

Aditya Sengupta (1), Kimberlee Gauvreau (1), Aditya Kaza (1), Katherine Kohlsaat (1), Pedro del Nido (1), Meena Nathan (1), (1) Boston Children's Hospital, Boston, MA

David Winlaw

Invited Discussant

David Winlaw is a congenital cardiac surgeon who works at The Ann & Robert H. Lurie Children's Hospital of Chicago. His interests include neonatal cardiac surgery, outcomes of the single ventricle pathway, genetics of congenital heart disease and bioengineering.

Aditya Sengupta

Abstract Presenter

Aditya Sengupta is a PGY-4 resident in the 6-year Integrated Cardiothoracic Surgery Training Program at The Mount Sinai Hospital in New York. Under the mentorship of Dr. Pedro del Nido and Dr. Meena Nathan, Aditya completed a two-year postdoctoral research fellowship in the Department of Cardiac Surgery at Boston Children's Hospital and concurrently obtained an MPH from the Harvard T. H. Chan School of Public Health. He aims to pursue a career in academic congenital cardiac surgery.

Specialties: Congenital, Procedures, Anatomy and Conditions, Hypoplastic Left Heart Syndrome, Single Ventricle, Treatment/Procedure/Operation/Surgery