Outcomes After Hybrid Palliation for Infants With Critical Left Heart Obstruction

Madison B Argo; David J Barron; Pirooz Eghtesady; Can Yerebakan; Williams M DeCampli; Bahaaldin Alsoufi; Osami Honjo; Jeffrey P Jacobs; Tharini Paramananthan; Maha Rahman; Linda M Lambert; Anusha Jegatheeswaran; Sergio A Carrillo; S Adil Husain; Karthik Ramakrishnan; Christopher A Caldarone; Tara Karamlou; Jennifer Nelson; Chelsea Mannie; Jennifer C Romano; Joseph W Turek; Eugene H Blackstone; Mark E Galantowicz; James K Kirklin; Michael E Mitchell; Brian W McCrindle; Congenital Heart Surgeons Society Critical Left Heart Obstruction Work Group

doi:10.1016/j.jacc.2023.07.020

Outcomes After Hybrid Palliation for Infants With Critical Left Heart Obstruction

J Am Coll Cardiol. 2023 Oct 3;82(14):1427-1441. doi: 10.1016/j.jacc.2023.07.020.

Authors

Madison B Argo¹, David J Barron², Pirooz Eghtesady³, Can Yerebakan⁴, Williams M DeCampli⁵, Bahaaldin Alsoufi⁶, Osami Honjo², Jeffrey P Jacobs⁷, Tharini Paramananthan², Maha Rahman², Linda M Lambert⁸, Anusha Jegatheeswaran⁹, Sergio A Carrillo¹⁰, S Adil Husain⁸, Karthik Ramakrishnan¹¹, Christopher A Caldarone¹², Tara Karamlou¹³, Jennifer Nelson¹⁴, Chelsea Mannie³, Jennifer C Romano¹⁵, Joseph W Turek¹⁶, Eugene H Blackstone¹³, Mark E Galantowicz¹⁰, James K Kirklin¹⁷, Michael E Mitchell¹⁸, Brian W McCrindle¹⁹; Congenital Heart Surgeons Society Critical Left Heart Obstruction Work Group

Affiliations

¹ Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA; 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 Pediatric Cardiothoracic Surgery, St Louis Children's Hospital, St Louis, Missouri, USA.
⁴ Division of Cardiac Surgery, Children's National Hospital, Washington, DC, USA.
⁵ Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, Florida, USA.
⁶ Department of Cardiovascular and Thoracic Surgery, Norton Children's Hospital, Louisville, Kentucky, USA.
⁷ Division of Cardiovascular Surgery, University of Florida, Gainesville, Florida, USA.
⁸ Division of Cardiothoracic Surgery, Primary Children's Hospital, Salt Lake City, Utah, USA.
⁹ Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children, London, United Kingdom.
¹⁰ Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA.
¹¹ Division of Pediatric Cardiovascular Surgery, LeBonheur Children's Hospital, Memphis, Tennessee, USA.
¹² Division of Congenital Heart Surgery, Texas Children's Hospital, Houston, Texas, USA.
¹³ Department of Thoracic and Cardiovascular Surgery and Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA.
¹⁴ Division of Pediatric Cardiovascular Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA.
¹⁵ Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA.
¹⁶ Department of Surgery, Duke Children's Hospital and Health Center, Durham, North Carolina, USA.
¹⁷ Division of Cardiothoracic Surgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA.
¹⁸ Division of Pediatric Cardiothoracic Surgery, Children's Wisconsin, Milwaukee, Wisconsin, USA.
¹⁹ Division of Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada. Electronic address: [email protected].

PMID: 37758438
DOI: 10.1016/j.jacc.2023.07.020

Abstract

Background: Hybrid palliation (bilateral pulmonary artery banding with or without ductal stenting) is an initial management strategy for infants with critical left heart obstruction and serves as palliation until subsequent operations are pursued.

Objectives: This study sought to determine patient characteristics and factors associated with subsequent outcomes for infants who underwent hybrid palliation.

Methods: From 2005 to 2019, 214 of 1,236 prospectively enrolled infants within the Congenital Heart Surgeons' Society's critical left heart obstruction cohort underwent hybrid palliation across 24 institutions. Multivariable hazard modeling with competing risk methodology was performed to determine risk and factors associated with outcomes of biventricular repair, Fontan procedure, transplantation, or death.

Results: Preoperative comorbidities (eg, prematurity, low birth weight, genetic syndrome) were identified in 70% of infants (150 of 214). Median follow-up was 7 years, ranging up to 17 years. Overall 12-year survival was 55%. At 5 years after hybrid palliation, 9% had biventricular repair, 36% had Fontan procedure, 12% had transplantation, 35% died without surgical endpoints, and 8% were alive without an endpoint. Factors associated with transplantation were absence of ductal stent, older age, absent interatrial communication, smaller aortic root size, larger tricuspid valve area z-score, and larger left ventricular volume. Factors associated with death were low birth weight, concomitant genetic syndrome, cardiopulmonary bypass use during hybrid palliation, moderate to severe tricuspid valve regurgitation, and smaller ascending aortic size.

Conclusions: Mortality remains high after hybrid palliation for infants with critical left heart obstruction. Nonetheless, hybrid palliation may facilitate biventricular repair for some infants and for others may serve as stabilization for intended functional univentricular palliation or primary transplantation.

Keywords: Fontan procedure; congenital heart disease; hypoplastic left heart syndrome; pulmonary artery banding.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Fontan Procedure*
Heart Block
Heart Ventricles / abnormalities
Heart Ventricles / diagnostic imaging
Heart Ventricles / surgery
Humans
Hypoplastic Left Heart Syndrome* / surgery
Infant
Palliative Care
Retrospective Studies
Treatment Outcome
Tricuspid Valve Insufficiency*