The Optimal Timing of Stage-2-Palliation After the Norwood Operation

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Society of Thoracic Surgeons 53rd Annual Meeting

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The Optimal Timing of Stage-2-Palliation After the Norwood Operation James M. Meza, MD, Edward Hickey, MD, MS, Brian McCrindle, MD, MPH, Eugene Blackstone, MD, Brett Anderson, MD, MBA, David Overman, MD, James K. Kirklin, MD, Tara Karamlou, MD, Christopher Caldarone, MD, Richard Kim, MD, William DeCampli, MD, PhD, Marshall Jacobs, MD, Kristine Guleserian, MD, Jeffrey P. Jacobs, MD, Robert Jaquiss, MD The Annals of Thoracic Surgery Volume 105, Issue 1, Pages 193-199 (January 2018) DOI: 10.1016/j.athoracsur.2017.05.041 Copyright © 2018 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Outcomes of patients who underwent an initial Norwood operation. (BVR = biventricular repair; OHT = orthotopic heart transplantation; S2P = stage-2-palliation.) The Annals of Thoracic Surgery 2018 105, 193-199DOI: (10.1016/j.athoracsur.2017.05.041) Copyright © 2018 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 (A) Age at stage-2-palliation (S2P) by mortality status after S2P: dead (red bars) or alive (green bars). (B) Age at S2P, by risk group: high (red); intermediate (green); or low (blue). (# = number.) The Annals of Thoracic Surgery 2018 105, 193-199DOI: (10.1016/j.athoracsur.2017.05.041) Copyright © 2018 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Analysis scheme. Parametric models for each interval and outcome were built based on the cumulative hazard derived from Kaplan-Meier survival estimates. The black circles represent the Kaplan-Meier estimates with their 95% confidence limits. The red lines represent the parametric models, with the dashed red lines representing the 70% confidence limits. This study’s objective was to determine how the timing of stage-2-palliation (S2P) can minimize the risk of death across the entire course from Norwood onward. The Annals of Thoracic Surgery 2018 105, 193-199DOI: (10.1016/j.athoracsur.2017.05.041) Copyright © 2018 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 (A) Predicted 2-year, post-Norwood survival over time in low-risk patients stratified by 2 (red), 4 (black), 6 (blue), or 8 (purple) months of age at stage-2-palliation (S2P). Patient characteristics: no interval reoperation, birth weight 3.0 kg, right ventricle to pulmonary artery conduit, oxygen saturation at end of Norwood 89%, baseline ascending aorta diameter 2.5 mm, no pre-S2P right ventricular dysfunction, weight-for-age z-score at pre-S2P cardiac catheterization 0.1, did not require extracorporeal membrane oxygenation after Norwood. (B) Predicted 2-year, post-Norwood survival over time for an intermediate-risk patients, stratified by 2 (red), 4 (green), 6 (black), or 8 (purple) months of age at S2P. Patient characteristics: no interval reoperation, birth weight 3.0 kg, right ventricle to pulmonary artery conduit, oxygen saturation at the end of the Norwood 72%, baseline ascending aorta diameter 2.0 mm, no pre-S2P right ventricle dysfunction, weight-for-age z-score -1.1, no extracorporeal membrane oxygenation after Norwood. (C) Predicted 2-year, post-Norwood survival versus age at S2P for low-risk (blue) and intermediate-risk (green) patients. Dashed lines represent 70% confidence limits. Patient characteristics are as in (A) low risk, and (B) intermediate risk. The Annals of Thoracic Surgery 2018 105, 193-199DOI: (10.1016/j.athoracsur.2017.05.041) Copyright © 2018 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 (A) Predicted 2-year, post-Norwood survival over time in high-risk patients stratified by 2 (red), 4 (black), 6 (gold), or 8 (purple) months of age at stage-2-palliation (S2P). Patient characteristics: no interval reoperation, birth weight 2.9 kg, right ventricle to pulmonary artery conduit, oxygen saturation at end of Norwood 75%, baseline ascending aorta diameter 1.5 mm, pre-S2P right ventricular dysfunction, weight-for-age z-score at pre-S2P cardiac catheterization −1.8, required extracorporeal membrane oxygenation after Norwood. (B) Predicted 2-year, post-Norwood survival versus age at S2P in high-risk post-S2P patients. Dashed lines represent 70% confidence limits. Patient characteristics are defined in (A). The Annals of Thoracic Surgery 2018 105, 193-199DOI: (10.1016/j.athoracsur.2017.05.041) Copyright © 2018 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Effects of specific risk factors on the optimal timing of stage-2-palliation (S2P). (A) Predicted 2-year, post-Norwood survival versus age at S2P stratified by shunt type: right ventricle to pulmonary artery (RVPA) conduit (blue), or modified Blalock-Taussig shunt (MBTS) (green). (B) Predicted 2-year, post-Norwood survival versus age at S2P stratified by interval cardiac reoperation (gold) or no interval reoperation (green). (C) Predicted 2-year, post-Norwood survival versus age at S2P stratified by pre-S2P right ventricular (RV) dysfunction (red) or no dysfunction (green). Patient characteristics, unless otherwise specified: no interval reoperation, birth weight 3.3 kg, MBTS, oxygen saturation at end of Norwood 80%, baseline ascending aorta diameter 1.5 mm, no pre-S2P RV dysfunction, weight-for-age z-score at pre-S2P cardiac catheterization −2.0, no extracorporeal membrane oxygenation after Norwood. The Annals of Thoracic Surgery 2018 105, 193-199DOI: (10.1016/j.athoracsur.2017.05.041) Copyright © 2018 The Society of Thoracic Surgeons Terms and Conditions

Supplemental Figure 1 The Annals of Thoracic Surgery 2018 105, 193-199DOI: (10.1016/j.athoracsur.2017.05.041) Copyright © 2018 The Society of Thoracic Surgeons Terms and Conditions