The impact of a standardized perioperative management on hospital mortality after the Norwood procedure in a low volume center: results and perspectives.

Abstract

Background: Mortality of newborns with Hypoplastic Left Heart Syndrome (HLHS) is mainly concentrated after Norwood procedure (NP) stage 1 palliation (S1P) and between S1P and stage 2 palliation (S2P). Standardized management of these patients may help to control hospital mortality. Aim of the study was to evaluate the impact on hospital mortality of a standardized perioperative management (SPM) for newborns requiring S1P in a low volume center for NP.

Methods: A consecutive series of patients undergoing S1P from January 1, 2002 to December 31, 2006 were retrospectively compared, by a "before and after" design, with those receiving a SPM (i.e. use of selective cerebral perfusion, near infrared spectroscopy, delayed sternal closure, modified ultrafiltration) from January 1^st, 2007 to December 31^st, 2018. Demographic, intraoperative and postoperative characteristics were collected. Univariate and multivariate analyses assessed differences before and after SPM.

Results: Ninety-one newborns underwent S1P in the considered period; of 74 eligible patients, 25 did not receive SPM, while 49 received SPM. Hospital mortality after S1P was 31% (CI 21-44%). The introduction of a SPM did not affect hospital mortality both at the univariate-(28% vs. 29%, P=0.959) and at the multivariate analysis (HR 1.85, P=0.62). Mortality was 12% (CI 6-25%) between hospital discharge after S1P and S2P and 8% (CI 3-22%) between S2P and S3P.

Conclusions: The use of a SPM for HLHS newborns requiring S1P was not effective in reducing hospital mortality in a low volume center. We suggest a collaboration between Italian Pediatric Cardiac Centers to manage HLHS patients.