13. Valved Sano Shunt Tends to Improve Immediate Outcomes Following Norwood Operation Compared to Non-Valved Sano Shunt
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Timothy Lancaster is Assistant Professor of Cardiac Surgery at the University of Michigan and C.S. Mott Children's Hospital. He completed medical school at Temple University and a 4/3 residency in general and cardiothoracic surgery at Washington University in St. Louis, before completing congenital cardiac surgery fellowship training at the University of Michigan. His clinical practice is in all aspects of pediatric and congenital cardiac surgery, with special interests in aortic valve and root surgery, adult congenital heart disease, and heart transplantation.
Columbia University
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David Kalfa, MD, PhD, is a Associate Professor of Surgery, in the Section of Pediatric & Congenital Cardiac Surgery at Columbia University Medical Center and Site Director, Pediatric cardiac Surgery, Weill-Cornell Medical Center. He is the Director of the Pediatric Heart Valve Center at Columbia and Surgical Director of the Initiative for Pediatric Cardiac Innovation at Columbia University. He is a NIH and AHA-funded surgeon scientist and an Irving Scholar at Columbia University. His clinical interests center around neonatal cardiac surgery, congenital valve repair, biventricular intracardiac reconstruction and minimally invasive surgery. Dr Kalfa also leads international research programs, focusing on development of innovative medical devices, tissue and mechanical engineering, computational modeling studies and precision medicine. Dr Kalfa's clinical and research expertise has been recognized and honored by many awards and grants. He is a AATS, STS, CHSS, EACTS, AHA member and a NIH reviewer.
Abstract
Methods: We retrospectively reviewed 25 consecutive HLHS neonates who underwent a valved Sano (VS) stage I operation using a femoral venous homograft and 25 consecutive HLHS neonates who underwent a standard non-valved Sano (NVS) between 2014 and 2022. Primary outcomes were ventricular function, tricuspid regurgitation, end-organ function, Sano and pulmonary artery (PA) reintervention, and survival at post-operative, discharge, interstage, and pre-Glenn time points.
Results: Perioperative characteristics and outcomes are summarized in Figure 1A. VS had a significantly lower peak lactate level (p=0.049), lactate 24 hours after peaking (p=0.02), time to diuresis (p=0.04), time to enteral feeds (p=0.02), and time to extubation (trend, p=0.08). No significant differences in mortality were seen during the hospital stay and interstage period (Fig 1A-C). The VS group had fewer patients requiring ECMO, experiencing cardiac arrest, and undergoing Sano and PA reinterventions prior to discharge following the Norwood operation (Fig 1A&B). The VS group trended towards fewer PA reinterventions overall (1 vs 7; p=0.116). Despite having worse ventricular function at baseline, the VS group showed significant improvement from the immediate post-operative period to discharge (Fig 1D arrow; p< 0.001). From preoperative to pre-Glenn time points, ventricular function within the VS was sustained, whereas ventricular function in the NVS group was significantly reduced by the time of pre-Glenn (Fig 1D; P<0.002). Pre-Glenn echocardiograms showed competent conduit valves in majority of the VS patients (n=16; 64%).
Conclusions: The VS is, or tends to be, associated with 1) improved multi-organ recovery and stability postoperatively, as demonstrated by lower lactate levels, time to diuresis, time to enteral feeds, and time to extubation; 2) increased hemodynamic stability, as exhibited by fewer patients needing ECMO or experiencing cardiac arrest postoperatively; 3) fewer PA reinterventions until stage II; and 4) augmented ventricular function recovery during stage I hospital stay. Assessment of mid- and long-term outcomes is warranted to evaluate the impact of valved Sano after stages II and III.