Hybrid palliation versus nonhybrid management for a multi-institutional cohort of infants with critical left heart obstruction

Madison B Argo; David J Barron; Igor Bondarenko; Aaron Eckhauser; Peter J Gruber; Linda M Lambert; Tharini Paramananthan; Maha Rahman; David S Winlaw; Can Yerebakan; Bahaaldin Alsoufi; William M DeCampli; Osami Honjo; James K Kirklin; Carol Prospero; Karthik Ramakrishnan; James D St Louis; Joseph W Turek; James E O'Brien Jr; Christian Pizarro; Petros V Anagnostopoulos; Eugene H Blackstone; Marshall L Jacobs; Anusha Jegatheeswaran; Tara Karamlou; Elizabeth H Stephens; Anastasios C Polimenakos; Marcus P Haw; Brian W McCrindle

doi:10.1016/j.jtcvs.2023.04.022

Hybrid palliation versus nonhybrid management for a multi-institutional cohort of infants with critical left heart obstruction

J Thorac Cardiovasc Surg. 2023 Nov;166(5):1300-1313.e2. doi: 10.1016/j.jtcvs.2023.04.022. Epub 2023 May 8.

Authors

Madison B Argo¹, David J Barron², Igor Bondarenko³, Aaron Eckhauser⁴, Peter J Gruber⁵, Linda M Lambert⁴, Tharini Paramananthan², Maha Rahman², David S Winlaw⁶, Can Yerebakan⁷, Bahaaldin Alsoufi⁸, William M DeCampli⁹, Osami Honjo², James K Kirklin¹⁰, Carol Prospero¹¹, Karthik Ramakrishnan¹², James D St Louis¹³, Joseph W Turek¹⁴, James E O'Brien Jr¹⁵, Christian Pizarro¹⁶, Petros V Anagnostopoulos¹⁷, Eugene H Blackstone¹⁸, Marshall L Jacobs¹⁹, Anusha Jegatheeswaran²⁰, Tara Karamlou¹⁸, Elizabeth H Stephens²¹, Anastasios C Polimenakos¹³, Marcus P Haw²², Brian W McCrindle²³

Affiliations

¹ Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wis; Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.
² Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.
³ Division of Cardiovascular Surgery, Children's Hospital of Michigan, Detroit, Mich.
⁴ Division of Cardiothoracic Surgery, Primary Children's Hospital, Salt Lake City, Utah.
⁵ Division of Cardiothoracic Surgery, Yale New Haven Children's Hospital, New Haven, Conn.
⁶ Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
⁷ Division of Cardiac Surgery, Children's National Hospital, Washington, DC.
⁸ Department of Cardiovascular and Thoracic Surgery, Norton Children's Hospital, Louisville, Ky.
⁹ Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, Fla.
¹⁰ Division of Cardiothoracic Surgery, The University of Alabama at Birmingham, Birmingham, Ala.
¹¹ Division of Pediatric Cardiology, Nemours Children's Hospital Delaware, Wilmington, Del.
¹² Division of Pediatric Cardiovascular Surgery, LeBonheur Children's Hospital, Memphis, Tenn.
¹³ Division of Pediatric and Congenital Cardiac Surgery, Children's Hospital of Georgia, Augusta, Ga.
¹⁴ Department of Surgery, Duke Children's Hospital and Health Center, Durham, NC.
¹⁵ Division of Pediatric Cardiovascular Surgery, Children's Mercy Kansas City, Kansas City, M.
¹⁶ Cardiothoracic Surgery, Nemours Children's Hospital Delaware, Wilmington, Del.
¹⁷ Division of Pediatric Cardiothoracic Surgery, University of Wisconsin Health American Family Hospital, Madison, Wis.
¹⁸ Department of Thoracic and Cardiovascular Surgery and Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
¹⁹ Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.
²⁰ Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children, London, United Kingdom.
²¹ Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
²² Department of Pediatric Cardiovascular Surgery, Helen DeVos Children's Hospital, Grand Rapids, Mich.
²³ Division of Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada. Electronic address: [email protected].

PMID: 37164059
DOI: 10.1016/j.jtcvs.2023.04.022

Abstract

Objective: To compare patient characteristics and overall survival for infants with critical left heart obstruction after hybrid palliation (bilateral pulmonary artery banding with or without ductal stenting) versus nonhybrid management (eg, Norwood, primary transplantation, biventricular repair, or transcatheter/surgical aortic valvotomy).

Methods: From 2005 to 2019, 1045 infants in the Congenital Heart Surgeons' Society critical left heart obstruction cohort underwent interventions across 28 institutions. Using a balancing score propensity analysis, 214 infants who underwent hybrid palliation and 831 infants who underwent nonhybrid management were proportionately matched regarding variables significantly associated with mortality and variables noted to significantly differ between groups. Overall survival between the 2 groups was adjusted by applying balancing scores to nonparametric estimates.

Results: Compared with the nonhybrid management group, infants who underwent hybrid palliation had lower birth weight, smaller gestational age, and higher prevalence of in-utero interventions, noncardiac comorbidities, preoperative mechanical ventilation, absent interatrial communication, and moderate or severe mitral valve stenosis (all P values < .03). Unadjusted 12-year survival after hybrid palliation and nonhybrid management, was 55% versus 69%, respectively. After matching, 12-year survival after hybrid palliation versus nonhybrid management was 58% versus 63%, respectively (P = .37). Among matched infants born weighing <2.5 kg, 2-year survival after hybrid palliation versus nonhybrid management was 37% versus 51%, respectively (P = .22).

Conclusions: Infants born with critical left heart obstruction who undergo hybrid palliation have more high-risk characteristics and anatomy versus infants who undergo nonhybrid management. Nonetheless, after adjustment, there was no significant difference in 12-year survival after hybrid palliation versus nonhybrid management. Mortality remains high, and hybrid palliation confers no survival advantage, even for lower-birth-weight infants.

Keywords: Norwood; critical left heart obstruction; hybrid palliation; hypoplastic left heart syndrome; propensity score; pulmonary artery banding.