Prevention of early sudden circulatory collapse after the Norwood operation.
BACKGROUND
After modifications in our perioperative management protocol, we have observed a decrease in sudden circulatory collapse after the Norwood operation. The current study examines early outcomes after the Norwood operation in our unit in an attempt to identify variables that may have altered the risk of unexpected circulatory collapse.


RESULTS
We studied 105 consecutive neonates who underwent a Norwood operation in our institution. Our treatment protocol has changed in the past 3 years to include the use of alpha-blockade with phenoxybenzamine (POB) for systemic afterload reduction and selective cerebral perfusion. Forty-eight infants had selective cerebral perfusion. Forty-two infants received POB. Sixty patients had hypoplastic left heart syndrome. There was no difference in age, diagnosis, number of neonates with weight <2.5 kg, aortic size diameter <2 mm, highest preoperative lactate level, and shunt size indexed to body weight among patients with or without use of POB. Twenty-five infants had circulatory collapse during the first 72 hours. Twelve of them could be explained by technical issues. Thirteen others who appeared clinically stable had early sudden circulatory collapse without an apparent cause. Sixteen out of 25 neonates died. Of those with technical problems, 8 out of 12 died. Based on the hazard function, 3 incremental risk factors for early circulatory collapse were technical issue at operation (P<0.001), longer cross-clamp time (P<0.007), and no use of POB (P<0.002). For a technically successful operation, freedom from circulatory collapse at 72 hours is 95% with the use of POB versus 69% without (P<0.002). Diagnosis, aortic size, atrioventricular valve function, birth weight, age at operation, and total circulatory arrest time and were not predictive of early sudden circulatory collapse.


CONCLUSIONS
Recent changes in our treatment protocol have resulted in a decrease incidence of sudden circulatory collapse after the Norwood operation. Optimal surgical technique is the most important predictor of early survival. The use of aggressive afterload reduction with POB reduced the risk of early sudden arrest.
De Oliveira
Nilto C
NC
Division of Cardiovascular Surgery, Hospital for Sick Children, and University of Toronto, Toronto, Ontario, Canada.
Ashburn
David A
DA
Khalid
Faizah
F
Burkhart
Harold M
HM
Adatia
Ian T
IT
Holtby
Helen M
HM
Williams
William G
WG
Van Arsdell
Glen S
GS
D000317:Adrenergic alpha-Antagonists / Q000627:therapeutic use*; D015415:Biomarkers; D002315:Cardiopulmonary Bypass; D002316:Cardiotonic Agents / Q000627:therapeutic use; D019090:Case Management; D002560:Cerebrovascular Circulation; D015331:Cohort Studies; D003645:Death, Sudden / Q000453:epidemiology / Q000517:prevention & control; D004298:Dopamine / Q000627:therapeutic use; D004837:Epinephrine / Q000627:therapeutic use; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D018636:Hypoplastic Left Heart Syndrome / Q000601:surgery*; D007231:Infant, Newborn; D007773:Lactates / Q000097:blood; D008297:Male; D020105:Milrinone / Q000627:therapeutic use; D008991:Monitoring, Physiologic; D010166:Palliative Care / Q000379:methods*; D010477:Perfusion; D010643:Phenoxybenzamine / Q000627:therapeutic use*; D011182:Postoperative Care / Q000639:trends; D011183:Postoperative Complications / Q000401:mortality / Q000517:prevention & control*; D012121:Respiration, Artificial; D012306:Risk; D012769:Shock / Q000401:mortality / Q000517:prevention & control*; D016896:Treatment Outcome
D000317:Adrenergic alpha-Antagonists; D015415:Biomarkers; D002316:Cardiotonic Agents; D007773:Lactates; D010643:Phenoxybenzamine; D020105:Milrinone; D004298:Dopamine; D004837:Epinephrine