Commentary: Late attrition in Norwood populations: Kicking the can down the road?

Central MessageAttrition after stage 2 Norwood has not changed in 30 years. Improved neonatal outcomes may have created a fragile subpopulation of patients who did survive earlier eras and remain at risk.See Article page 385. Attrition risk. See We continue to learn from the unique experience Children's Hospital Philadelphia's (CHOP) analysis their program for hypoplastic left heart syndrome, with notable finding that attrition between 3 remained unchanged over past years.1Lawrence K.M. Ittenbach R.F. Hunt M.L. Kaplinski M. Ravishankar C. Rychik J. et al.Attrition superior cavopulmonary connection Fontan procedure syndrome.J Thorac Cardiovasc Surg. 2021; 162: 385-393Abstract Full Text PDF PubMed Scopus (4) Google Scholar It is an unexpected given remarkable progress been made this same time period. The dramatic improvements seen 1 interstage or still meant better overall survival population. So why constant CHOP series? most likely reason successes early management led some children, those would previously survived. However, ventricular dysfunction, persistent atrioventricular (AV) valve regurgitation poor pulmonary vasculature be problem beyond 2. Unfortunately, study unable answer key question because there are no data on function AV function—nor premorbid condition died. fact intervention prolonged length stay were strongly linked outcome suggest these surrogate markers patient group. Hence, simply kicked can down road terms managing challenging problems. On positive side, multivariate risk model does show tenacious risks repair, such as low weight prematurity, now ceased factors once through Although dataset appears very rich, was relatively limited much clinical available. extremely informative review results competing zero discharge hospital end states, including time-related transition Fontan, remaining alive without any additional procedures, state attrition. Review features associated successful also provided deeper understanding patients. particularly important completeness follow-up 5% missing. other striking observation association right ventricle artery (RV-PA) conduit late This could reflect influence ventriculotomy long-term function, but lack detailed echocardiography/hemodynamic means we clarify this. Equally, RV-PA greatest highest-risk amongst intrinsically poorer RV function; words, kicking again. Any single-center inevitably hampered by institutional bias, which difficult control for: strong proponent Blalock-Taussig shunt only 17.5% cohort having conduit. They done so good outstanding, it remains unclear what criteria used favor each strategy whether groups truly comparable. Furthermore, high mortality eras2Mascio C.E. Irons Gaynor J.W. Fuller S.M. al.Thirty years 1663 consecutive procedures: plateaued?.J 2019; 158: 220-229Abstract (35) exclusively shunt, surviving population self-selected more robust survivors. Multicenter studies able mitigate effects practice, Congenital Heart Surgeons' Society study3Wilder T.J. McCrindle B.W. Phillips A.B. Blackstone E.H. Rajeswaran Williams W.G. al.Survival performance matched children stage-1 Norwood: modified versus right-ventricle-to-pulmonary-artery conduit.J 2015; 150: 1440-1450Abstract (52) suggesting continued benefit group well period, Single Ventricle Reconstruction Trial showing increased attrition.4Newburger Sleeper L.A. Hollenbeck-Pringle D. Frommelt P.C. Li J.S. al.Transplant-free interventions 6 SVR trial.Circulation. 2018; 137: 2246-2253Crossref (91) Nevertheless, during first 13 months should encourage us focus age try duplicate monitoring preempting deterioration. syndromeThe Journal Thoracic Cardiovascular SurgeryVol. 162Issue 2PreviewWe investigated incidence predictors failure undergo syndrome survived connection. Full-Text