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J Thorac Cardiovasc Surg 2010;139:962-968
© 2010 The American Association for Thoracic Surgery

Congenital Heart Disease

Stage I Norwood: Optimal technical performance improves outcomes irrespective of preoperative physiologic status or case complexity

^a Department of Cardiac Surgery, Children's Hospital Boston, Boston, Mass
^b Department of Cardiology, Children's Hospital Boston, Boston, Mass
^c Harvard Medical School, Boston, Mass

Received for publication June 15, 2009; revisions received September 8, 2009; accepted for publication October 5, 2009.

^_* Address for reprints: Emile A. Bacha, MD, Department of Cardiac Surgery, Children's Hospital Boston, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115. (Email: emile.bacha{at}cardio.chboston.org).

Objective: Interplay of baseline physiologic status, case complexity, technical performance, and outcomes in high-acuity operations has been poorly defined. This study explored these interactions to determine whether a technically optimal operation can mitigate effects of baseline physiology and high case-complexity on outcomes for the stage I Norwood procedure.

Methods: Technical performance was categorized as optimal, adequate, or inadequate from adequacy of the anatomic repair of the stage I subprocedures according to anatomic areas where intervention is performed. Physiological illness severity statuses in preoperative and postoperative periods were determined with Pediatric Risk of Mortality III system, which uses 17 physiologic variables. Case complexity was calculated with Aristotle comprehensive system. All patients undergoing stage I procedure from January 2004 to December 2007 were retrospectively studied.

Results: One hundred thirty-five procedures were included. Five were excluded from the technical performance assessment because of inadequate postoperative data. Eighty-one (62.3%), 26 (20%), and 23 (17.7%), respectively, were scored as optimal, adequate, and inadequate. Overall hospital mortality was 14.1%. Inadequate technical performance, high-complexity Aristotle comprehensive scores, and high preoperative illness severity scores correlated with significantly higher hospital mortality, longer stay, and greater frequency of major postoperative complications. In subgroup analysis of patients with optimal technical performance, outcomes were favorable irrespective of high or low preoperative physiologic illness severity or case complexity.

Conclusions: In stage I Norwood procedures, optimal technical performance attenuated effects of poor preoperative physiologic status and high case complexity, with reduced hospital mortality. Inadequate technical performance resulted in poor outcomes regardless of preoperative status.

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