title: An institutional experience with second- and third-stage palliative procedures for hypoplastic left heart syndrome: the impact of the bidirectional cavopulmonary shunt.
abstract: OBJECTIVE
  The aim of this study was to perform a retrospective analysis of an institutional experience with a consecutive series of patients with post-stage I palliation for hypoplastic left heart syndrome (HLHS).
  
  
  BACKGROUND
  In a recent review of 212 consecutive patients who underwent stage I operations for HLHS at our institution between 1983 and 1993, we identified risk factors related to stage I mortality. We sought to examine the outcome for these patients at subsequent palliative procedures.
  
  
  METHODS
  All patients who underwent stage I reconstruction between January 1983 and June 1993 and also underwent subsequent palliation at our institution were included. Seventy patients underwent palliative procedures and two underwent heart transplantation. Patient-specific factors and features of the stage II operation were analyzed for impact on stage II mortality and actuarial survival.
  
  
  RESULTS
  The only independent risk factor for stage II mortality was the performance of a nonfenestrated Fontan operation (p < 0.001). There were nine in-hospital deaths (69%) in the 13 patients undergoing the nonfenestrated Fontan procedure at stage II. Fifty patients underwent intermediate superior vena cava to pulmonary artery anastomosis at stage II, with 4 (8%) early deaths. Pulmonary artery augmentation was performed in 19 patients (38%) at stage II, without increased operative risk. Hypoplastic left heart syndrome anatomic subtype did not influence stage II mortality. The modified fenestrated Fontan procedure has been performed as a third stage in 32 patients whose median age was 28.7 months, with one early death at a median follow-up of 24.5 months.
  
  
  CONCLUSIONS
  A second-stage bidirectional cavopulmonary anastomosis for HLHS reduces second-stage mortality and improves intermediate survival. The modified fenestrated Fontan operation may then be performed as a final palliative stage with low operative risk.
authors.affiliation: Department of Cardiovascular Surgery, Children's Hospital, Boston, Massachusetts 02115, USA.
authors.forename: J M
authors.initials: JM
authors.lastname: Forbess
authors.forename: N
authors.initials: N
authors.lastname: Cook
authors.forename: A
authors.initials: A
authors.lastname: Serraf
authors.forename: R P
authors.initials: RP
authors.lastname: Burke
authors.forename: J E
authors.initials: JE
authors.lastname: Mayer
authors.forename: R A
authors.initials: RA
authors.lastname: Jonas
mesh_terms: D002675:Child, Preschool; D005260:Female; D018729:Fontan Procedure; D018610:Heart Bypass, Right / Q000379:methods* / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D018636:Hypoplastic Left Heart Syndrome / Q000150:complications / Q000401:mortality / Q000601:surgery*; D007223:Infant; D008297:Male; D010166:Palliative Care; D012189:Retrospective Studies; D012307:Risk Factors; D016019:Survival Analysis