Risk factors for failed staged palliation after bidirectional Glenn in infants who have undergone stage one palliation

Abstract

Objective: The bidirectional Glenn procedure (BDG) is a routine intermediary step in single-ventricle palliation. In this study, we examined risk factors for death or transplant and failure to reach Fontan completion after BDG in patients, who had previously undergone stage one palliation (S1P).

Methods: All patients at our institution, who underwent BDG following S1P between 2002 and 2009 (n=194), were included in the analysis.

Results: Transplant-free survival through 18 months post BDG was 91%. Univariable competing risk analyses showed atrioventricular valve regurgitation (AVVR) >mild, age ≤ 3 months at BDG, ventricular dysfunction >mild, and prolonged hospital stay after S1P to be associated with increased risk of death or orthotopic heart transplant. Multivariable competing risk analysis through 5 years of follow-up showed >mild AVVR (hazard ratio (HR) 7.5, 95% confidence interval (CI) 3.0-18.8), prolonged hospitalization after S1P (HR 4.5, 95% CI 1.8-11.5), and age ≤ 3 months at BDG (HR 6.8, 95% CI 2.3-20.0) to be independent risk factors for death or transplant. Concomitantly, > mild AVVR and age ≤ 3 months were independently associated with an overall decreased rate of Fontan completion.

Conclusions: Pre-BDG AVVR, age ≤ 3 months at time of BDG, and prolonged hospitalization after S1P are independently associated with decreased successful progression of staged palliation in midterm follow-up after BDG.

Fig. 1

Outcome of 194 patients after BDG following a comprehensive S1P from 2002 through 2009. BDG, bidirectional Glenn procedure; OHT, orthotopic heart transplant.

Fig. 2

A–D: Competing risk analysis. Panel A: Competing time-dependent outcomes for the entire cohort. Panel B: Competing outcomes stratified by the degree of preoperative AVVR (≤mild vs >mild). Panel C: Competing outcomes comparing those with age ≤3 months vs age >3 months at BDG. Panel D: Competing outcomes comparing prolonged S1P hospital stay versus typical S1P hospital stay. BDG, bidirectional Glenn procedure; CI, confidence interval; S1P, stage one palliation; AVVR, atrioventricular valve regurgitation; and OHT, orthotopic heart transplant. Prolonged S1P hospital stay defined as hospitalization length of stay in the highest decile.