• James M Meza, Edward J Hickey, Eugene H Blackstone, JaquissRobert D BRDBFrom Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada (J.M.M., E.J.H., W.G.W., S.C., G.S.V.A.); Departments of Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clini, Brett R Anderson, William G Williams, Sally Cai, Glen S Van Arsdell, Tara Karamlou, and Brian W McCrindle.
• From Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada (J.M.M., E.J.H., W.G.W., S.C., G.S.V.A.); Departments of Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B.); Division of Pediatric Cardiothoracic Surgery, Children's Medical Center, Dallas, TX (R.D.B.J.); Division of Pediatric Cardiology, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Division of Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, AZ (T.K.); and Division of Pediatric Cardiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada (B.W.M.). james.meza@sickkids.ca.
• Circulation. 2017 Oct 31; 136 (18): 1737-1748.

BackgroundIn infants requiring 3-stage single-ventricle palliation for hypoplastic left heart syndrome, attrition after the Norwood procedure remains significant. The effect of the timing of stage 2 palliation (S2P), a physician-modifiable factor, on long-term survival is not well understood. We hypothesized that an optimal interval between the Norwood and S2P that both minimizes pre-S2P attrition and maximizes post-S2P survival exists and is associated with individual patient characteristics.MethodsThe National Institutes of Health/National Heart, Lung, and Blood Institute Pediatric Heart Network Single Ventricle Reconstruction Trial public data set was used. Transplant-free survival (TFS) was modeled from (1) Norwood to S2P and (2) S2P to 3 years by using parametric hazard analysis. Factors associated with death or heart transplantation were determined for each interval. To account for staged procedures, risk-adjusted, 3-year, post-Norwood TFS (the probability of TFS at 3 years given survival to S2P) was calculated using parametric conditional survival analysis. TFS from the Norwood to S2P was first predicted. TFS after S2P to 3 years was then predicted and adjusted for attrition before S2P by multiplying by the estimate of TFS to S2P. The optimal timing of S2P was determined by generating nomograms of risk-adjusted, 3-year, post-Norwood, TFS versus the interval from the Norwood to S2P.ResultsOf 547 included patients, 399 survived to S2P (73%). Of the survivors to S2P, 349 (87%) survived to 3-year follow-up. The median interval from the Norwood to S2P was 5.1 (interquartile range, 4.1-6.0) months. The risk-adjusted, 3-year, TFS was 68±7%. A Norwood-S2P interval of 3 to 6 months was associated with greatest 3-year TFS overall and in patients with few risk factors. In patients with multiple risk factors, TFS was severely compromised, regardless of the timing of S2P and most severely when S2P was performed early. No difference in the optimal timing of S2P existed when stratified by shunt type.ConclusionsIn infants with few risk factors, progressing to S2P at 3 to 6 months after the Norwood procedure was associated with maximal TFS. Early S2P did not rescue patients with greater risk factor burdens. Instead, referral for heart transplantation may offer their best chance at long-term survival.Clinical Trial RegistrationURL: https://www.clinicaltrials.gov. Unique identifier: NCT00115934.© 2017 American Heart Association, Inc.

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