Association of Interstage Monitoring Era and Likelihood of Hemodynamic Compromise at Intervention for Recoarctation Following the Norwood Operation

Abstract

Background Intensive monitoring has been associated with a lower death rate between the Norwood operation and superior cavopulmonary connection, possibly due to early identification and effective treatment of residual anatomic lesions like recoarctation before lasting harm occurs. Methods and Results Neonates undergoing a Norwood operation and receiving interstage care at a single center between January 1, 2005, and September 18, 2020, were studied. In those with recoarctation, we evaluated association of era ([1] preinterstage monitoring, [2] a transitional phase, [3] current era) and likelihood of hemodynamic compromise (progression to moderate or greater ventricular dysfunction/atrioventricular valve regurgitation, initiation/escalation of vasoactive/respiratory support, cardiac arrest preceding catheterization, or interstage death with recoarctation on autopsy). We also analyzed whether era was associated with technical success of transcatheter recoarctation interventions, major adverse events, and transplant-free survival. A total of 483 subjects were studied, with 22% (n=106) treated for recoarctation during the interstage period. Number of catheterizations per Norwood increased (P=0.005) over the interstage eras, with no significant change in the proportion of subjects with recoarctation (P=0.36). In parallel, there was a lower likelihood of hemodynamic compromise in subjects with recoarctation that was not statistically significant (P=0.06), with a significant difference in the proportion with ventricular dysfunction at intervention (P=0.002). Rates of technical success, procedural major adverse events, and transplant-free survival did not differ (P>0.05). Conclusions Periods with interstage monitoring were associated with increased referral for catheterization but also reduced likelihood of ventricular dysfunction (and a suggestion of lower likelihood of hemodynamic compromise) in subjects with recoarctation. Further study is needed to guide optimal interstage care of this vulnerable population.

Keywords: aortic recoarctation; congenital heart disease; hypoplastic left heart syndrome; interventional cardiology; single ventricle.

Figure 1. Study population.

Six patients were found to have recoarctation on autopsy but had not previously undergone transcatheter intervention for recoarctation. SV indicates single ventricle; and SCPC, superior cavopulmonary anastomosis.

Figure 2. Association of era and hemodynamic compromise in patients with recoarctation (N=106; era 1, n=40; era 2, n=11; era 3, n=55).

Data are presented as percentages with 95% CIs. P values were calculated with Fisher's exact test with pairwise comparisons by era conducted using a Bonferroni correction.

Figure 3. Number of catheterizations per Norwood recipient (N=483; era 1, n=208; era 2, n=48; era 3, n=227).

Data are presented as means with 95% CIs. Overall P value was calculated with ANOVA, and pairwise comparisons by era were conducted with Tukey's test.

Figure 4. Transplant‐free survival in patients with recoarctation (N=106; era, 1 n=40; era 2, n=11; era 3, n=55).

Overall P value was calculated using the log‐rank test. Pairwise comparisons between survival curves were performed with the log‐rank test and revealed no statistically significant differences (era 1 vs era 2, P=0.32; era 1 vs era 3, P=0.92; era 2 vs era 3, P=0.32).