Karamlou Tara, Sexson Kristen, Parrish Andrea, Welke Karl F, McMullan D Michael, Permut Lester, Cohen Gordon
Division of Pediatric Cardiac Surgery, Benioff Children's Hospital, University of California, San Francisco, 513 Parnassus Avenue, Suite S-549, California, CA 94143, USA.
J Cardiothorac Surg. 2014 Jun 14;9:100. doi: 10.1186/1749-8090-9-100.
Given our large catchment area that often results in later presentation age, we sought to understand our institutional outcomes for the Norwood operation in the context of published data. Specifically, we studied whether operative and late death post-Norwood are dependent on age at operation.
Retrospective review of 105 consecutive infants undergoing Norwood (2004-2011) at our institution. Patients were divided into those undergoing Norwood ≤ 7 days of age (N = 43; 41%) and those undergoing Norwood > 7 days of age (N = 63; 59%). Operative mortality (≥30 days), interstage mortality (between Norwood and superior bidirectional Glenn), STS-mortality (operative death + in-hospital death), and late mortality, occurring any time following hospital discharge were compared among groups. Multivariable factors for mortality at each time-point were compared using logistic regression models.
Underlying diagnosis was HLHS in 67 (64%) with the remainder (N = 38; 36%) being other single ventricle variants. Median age at surgery was 8 days (range 1-63 days) and mean weight at surgery was 3.2 ± 0.6 kg. Pulmonary blood flow was provided by a right ventricle-pulmonary artery conduit in 94% (N = 99). Overall operative survival was 92%, with 73% (N = 66) undergoing bidirectional Glenn. Median age was higher for operative survivors compared to non-survivors (12 days vs. 5 days; P = 0.036), with operative mortality higher for infants ≤7 days at Norwood compared to infants >7 days at Norwood (14% vs. 3%; P = 0.04). After censoring for in-hospital death, age ≤ 7 days was also associated with increased risk for late death (26% vs. 5%; P = 0.005).
In contrast to other institutional series, infants at our center undergoing Norwood operation at an earlier age have worse outcomes. Adoption of published practice patterns could lead to different local outcomes because of intangible center-specific effects, underscoring the principle that results from one institution may not be generalizable to others. Targeted center-specific internal review, if possible, should precede externally recommended changes in practice.
鉴于我们的大集水区常常导致患儿就诊年龄偏大，我们试图在已发表数据的背景下了解我们机构开展诺伍德手术的结果。具体而言，我们研究了诺伍德手术后的手术死亡率和晚期死亡率是否取决于手术时的年龄。
对我院2004年至2011年连续接受诺伍德手术的105例婴儿进行回顾性研究。将患者分为诺伍德手术时年龄≤7天的患儿（n = 43；41%）和诺伍德手术时年龄>7天的患儿（n = 63；59%）。比较两组间的手术死亡率（≥30天）、分期手术死亡率（诺伍德手术与上腔静脉双向格林手术之间）、胸外科医师协会定义的死亡率（手术死亡+住院死亡）以及出院后任何时间发生的晚期死亡率。使用逻辑回归模型比较每个时间点死亡率的多变量因素。
67例（64%）的潜在诊断为左心发育不全综合征，其余38例（36%）为其他单心室病变。手术时的中位年龄为8天（范围1 - 63天），手术时的平均体重为3.2±0.6千克。94%（n = 99）的患儿通过右心室 - 肺动脉导管提供肺血流。总体手术生存率为92%，其中73%（n = 66）接受了双向格林手术。手术存活者的中位年龄高于非存活者（12天对5天；P = 0.036），诺伍德手术时年龄≤7天的婴儿的手术死亡率高于诺伍德手术时年龄>7天的婴儿（14%对3%；P = 0.04）。在剔除住院死亡因素后，年龄≤7天也与晚期死亡风险增加相关（26%对5%；P = 0.005）。
与其他机构的系列研究不同，我院中心年龄较小接受诺伍德手术的婴儿预后较差。由于无形的特定中心效应，采用已发表的实践模式可能会导致不同的局部结果，这突出了一个原则，即一个机构的结果可能不适用于其他机构。如有可能，在外部推荐的实践改变之前，应先进行有针对性的特定中心内部审查。
