In search of the ideal pulmonary blood source for the norwood procedure: A meta-analysis and systematic review

Vikas Sharma, Salil V. Deo, Marianne Huebner, Joseph A. Dearani, Harold M. Burkhart

Research output: Contribution to journalArticle

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Abstract

Background A clear consensus regarding the optimal source of pulmonary blood flow in patients with hypoplastic left heart syndrome undergoing the Norwood procedure is lacking. Methods A literature search was undertaken to identify relevant articles from 2005 to 2012 using "Norwood, stage 1 palliation," "Modified Blalock Taussig shunt (MBTS)," "right ventricle-to-pulmonary artery shunt (RV-PAS)" alone or in combination. Three end points were selected: early/stage 1 mortality, interstage mortality, and interstage total/shunt intervention. Results A total of 20 articles, including 19 observational studies and 1 randomized trial (MBTS, n = 1,343; RV-PAS, n = 1,028), met the inclusion criteria. Mortality after stage 1 was 22% in the MBTS cohort and 16% in RV-PAS cohort. A pooled analysis showed no difference in early mortality between the two groups (risk ratio [RR], 1.20; 95% confidence interval [CI], 0.99 to 1.45; p = 0.07). On pooling data from contemporary series (similar era) of 8 studies (MBTS, n = 709; RV-PAS, n = 631), to minimize variability in surgical and postoperative management practices, early mortality in both cohorts was comparable (RR, 1.14; 95% CI, 0.89 to 1.45; p = 0.29). Interstage mortality was 13.8% and 4.6% in the MBTS and RV-PAS cohorts, respectively, and was significantly lower for RV-PAS (RR, 2.85; 95% CI, 1.65 to 4.89; p < 0.00002). However, patients with MBTS had fewer shunt interventions (RR, 0.55; 95% CI, 0.44 to 0.68; p < 0.001; I2 = 00%). Conclusions Our pooled analysis demonstrated no survival benefit for the MBTS or RV-PAS in patients undergoing the Norwood procedure. There appears to be an advantage with the RV-PAS with regard to interstage mortality at the cost of an increased rate of shunt intervention.

Original languageEnglish (US)
Pages (from-to)142-150
Number of pages9
JournalAnnals of Thoracic Surgery
Volume98
Issue number1
DOIs
StatePublished - 2014

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Norwood Procedures
Blalock-Taussig Procedure
Pulmonary Artery
Heart Ventricles
Meta-Analysis
Lung
Mortality
Odds Ratio
Confidence Intervals
Hypoplastic Left Heart Syndrome
Practice Management
Observational Studies

ASJC Scopus subject areas

  • Surgery
  • Pulmonary and Respiratory Medicine
  • Cardiology and Cardiovascular Medicine

Cite this

In search of the ideal pulmonary blood source for the norwood procedure : A meta-analysis and systematic review. / Sharma, Vikas; Deo, Salil V.; Huebner, Marianne; Dearani, Joseph A.; Burkhart, Harold M.

In: Annals of Thoracic Surgery, Vol. 98, No. 1, 2014, p. 142-150.

Research output: Contribution to journalArticle

Sharma, Vikas ; Deo, Salil V. ; Huebner, Marianne ; Dearani, Joseph A. ; Burkhart, Harold M. / In search of the ideal pulmonary blood source for the norwood procedure : A meta-analysis and systematic review. In: Annals of Thoracic Surgery. 2014 ; Vol. 98, No. 1. pp. 142-150.
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T1 - In search of the ideal pulmonary blood source for the norwood procedure

T2 - A meta-analysis and systematic review

AU - Sharma, Vikas

AU - Deo, Salil V.

AU - Huebner, Marianne

AU - Dearani, Joseph A.

AU - Burkhart, Harold M.

PY - 2014

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N2 - Background A clear consensus regarding the optimal source of pulmonary blood flow in patients with hypoplastic left heart syndrome undergoing the Norwood procedure is lacking. Methods A literature search was undertaken to identify relevant articles from 2005 to 2012 using "Norwood, stage 1 palliation," "Modified Blalock Taussig shunt (MBTS)," "right ventricle-to-pulmonary artery shunt (RV-PAS)" alone or in combination. Three end points were selected: early/stage 1 mortality, interstage mortality, and interstage total/shunt intervention. Results A total of 20 articles, including 19 observational studies and 1 randomized trial (MBTS, n = 1,343; RV-PAS, n = 1,028), met the inclusion criteria. Mortality after stage 1 was 22% in the MBTS cohort and 16% in RV-PAS cohort. A pooled analysis showed no difference in early mortality between the two groups (risk ratio [RR], 1.20; 95% confidence interval [CI], 0.99 to 1.45; p = 0.07). On pooling data from contemporary series (similar era) of 8 studies (MBTS, n = 709; RV-PAS, n = 631), to minimize variability in surgical and postoperative management practices, early mortality in both cohorts was comparable (RR, 1.14; 95% CI, 0.89 to 1.45; p = 0.29). Interstage mortality was 13.8% and 4.6% in the MBTS and RV-PAS cohorts, respectively, and was significantly lower for RV-PAS (RR, 2.85; 95% CI, 1.65 to 4.89; p < 0.00002). However, patients with MBTS had fewer shunt interventions (RR, 0.55; 95% CI, 0.44 to 0.68; p < 0.001; I2 = 00%). Conclusions Our pooled analysis demonstrated no survival benefit for the MBTS or RV-PAS in patients undergoing the Norwood procedure. There appears to be an advantage with the RV-PAS with regard to interstage mortality at the cost of an increased rate of shunt intervention.

AB - Background A clear consensus regarding the optimal source of pulmonary blood flow in patients with hypoplastic left heart syndrome undergoing the Norwood procedure is lacking. Methods A literature search was undertaken to identify relevant articles from 2005 to 2012 using "Norwood, stage 1 palliation," "Modified Blalock Taussig shunt (MBTS)," "right ventricle-to-pulmonary artery shunt (RV-PAS)" alone or in combination. Three end points were selected: early/stage 1 mortality, interstage mortality, and interstage total/shunt intervention. Results A total of 20 articles, including 19 observational studies and 1 randomized trial (MBTS, n = 1,343; RV-PAS, n = 1,028), met the inclusion criteria. Mortality after stage 1 was 22% in the MBTS cohort and 16% in RV-PAS cohort. A pooled analysis showed no difference in early mortality between the two groups (risk ratio [RR], 1.20; 95% confidence interval [CI], 0.99 to 1.45; p = 0.07). On pooling data from contemporary series (similar era) of 8 studies (MBTS, n = 709; RV-PAS, n = 631), to minimize variability in surgical and postoperative management practices, early mortality in both cohorts was comparable (RR, 1.14; 95% CI, 0.89 to 1.45; p = 0.29). Interstage mortality was 13.8% and 4.6% in the MBTS and RV-PAS cohorts, respectively, and was significantly lower for RV-PAS (RR, 2.85; 95% CI, 1.65 to 4.89; p < 0.00002). However, patients with MBTS had fewer shunt interventions (RR, 0.55; 95% CI, 0.44 to 0.68; p < 0.001; I2 = 00%). Conclusions Our pooled analysis demonstrated no survival benefit for the MBTS or RV-PAS in patients undergoing the Norwood procedure. There appears to be an advantage with the RV-PAS with regard to interstage mortality at the cost of an increased rate of shunt intervention.

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