title: Doppler flow patterns in the right ventricle-to-pulmonary artery shunt and neo-aorta in infants with single right ventricle anomalies: impact on outcome after initial staged palliations.
abstract: BACKGROUND
  A Pediatric Heart Network trial compared outcomes in infants with single right ventricle anomalies undergoing Norwood procedures randomized to modified Blalock-Taussig shunt (MBTS) or right ventricle-to-pulmonary artery shunt (RVPAS). Doppler patterns in the neo-aorta and RVPAS may characterize physiologic changes after staged palliations that affect outcomes and right ventricular (RV) function.
  
  
  METHODS
  Neo-aortic cardiac index (CI), retrograde fraction (RF) in the descending aorta and RVPAS conduit, RVPAS/neo-aortic systolic ejection time ratio, and systolic/diastolic (S/D) ratio were measured early after Norwood, before stage II palliation, and at 14 months. These parameters were compared with transplantation-free survival, length of hospital stay, and RV functional indices.
  
  
  RESULTS
  In 529 subjects (mean follow-up period, 3.0 ± 2.1 years), neo-aortic CI and descending aortic RF were significantly higher in the MBTS cohort after Norwood. The RVPAS RF averaged <25% at both interstage intervals. Higher pre-stage II descending aortic RF was correlated with lower RV ejection fraction (R = -0.24; P = .032) at 14 months for the MBTS cohort. Higher post-Norwood CI (5.6 vs 4.4 L/min/m(2), P = .04) and lower S/D ratio (1.40 vs 1.68, P = .01) were correlated with better interstage transplantation-free survival for the RVPAS cohort. No other Doppler flow patterns were correlated with outcomes.
  
  
  CONCLUSIONS
  After the Norwood procedure, infants tolerated significant descending aortic RF (MBTS) and conduit RF (RVPAS), with little correlation with clinical outcomes or RV function. Neo-aortic CI, ejection time, and S/D ratios also had limited correlations with outcomes or RV function, but higher post-Norwood neo-aortic CI and lower S/D ratio were correlated with better interstage survival in those with RVPAS.
authors.affiliation: Medical College of Wisconsin, Milwaukee, WI 53226, USA. pfrommelt@chw.org
authors.forename: Peter C
authors.initials: PC
authors.lastname: Frommelt
authors.forename: Eric
authors.initials: E
authors.lastname: Gerstenberger
authors.forename: Jeanne
authors.initials: J
authors.lastname: Baffa
authors.forename: William L
authors.initials: WL
authors.lastname: Border
authors.forename: Tim J
authors.initials: TJ
authors.lastname: Bradley
authors.forename: Steven
authors.initials: S
authors.lastname: Colan
authors.forename: Jessica
authors.initials: J
authors.lastname: Gorentz
authors.forename: Haleh
authors.initials: H
authors.lastname: Heydarian
authors.forename: J Blaine
authors.initials: JB
authors.lastname: John
authors.forename: Wyman W
authors.initials: WW
authors.lastname: Lai
authors.forename: Jami
authors.initials: J
authors.lastname: Levine
authors.forename: Jimmy C
authors.initials: JC
authors.lastname: Lu
authors.forename: Rachel T
authors.initials: RT
authors.lastname: McCandless
authors.forename: Stephen
authors.initials: S
authors.lastname: Miller
authors.forename: Arni
authors.initials: A
authors.lastname: Nutting
authors.forename: Richard G
authors.initials: RG
authors.lastname: Ohye
authors.forename: Gail D
authors.initials: GD
authors.lastname: Pearson
authors.forename: Pierre C
authors.initials: PC
authors.lastname: Wong
authors.forename: Meryl S
authors.initials: MS
authors.lastname: Cohen
mesh_terms: D001013:Aorta, Thoracic / Q000601:surgery; D058366:Blalock-Taussig Procedure; D015150:Echocardiography, Doppler; D006352:Heart Ventricles / Q000002:abnormalities / Q000503:physiopathology; D006801:Humans; D018636:Hypoplastic Left Heart Syndrome / Q000000981:diagnostic imaging* / Q000601:surgery*; D007223:Infant; D007231:Infant, Newborn; D007902:Length of Stay; D058327:Norwood Procedures; D010166:Palliative Care; D011651:Pulmonary Artery / Q000002:abnormalities; D016896:Treatment Outcome; D016216:Ultrasonography, Prenatal
references.citation: J Am Soc Echocardiogr. 2007 Jun;20(6):749-55
references.pmid: 17543747
references.citation: J Thorac Cardiovasc Surg. 2012 Jul;144(1):152-9
references.pmid: 22341427
references.citation: Am J Cardiol. 2010 Aug 1;106(3):430-6
references.pmid: 20643259
references.citation: J Am Soc Echocardiogr. 2009 Aug;22(8):928-32
references.pmid: 19553081
references.citation: J Thorac Cardiovasc Surg. 2000 Jul;120(1):81-7
references.pmid: 10884659
references.citation: J Am Soc Echocardiogr. 2009 Feb;22(2):152-8
references.pmid: 19121569
references.citation: J Am Soc Echocardiogr. 2006 Nov;19(11):1326-31
references.pmid: 17098134
references.citation: J Am Coll Cardiol. 1985 Sep;6(3):653-62
references.pmid: 4031277
references.citation: Intern Med. 2010;49(19):2031-7
references.pmid: 20930426
references.citation: Circulation. 2012 May 29;125(21):2630-8
references.pmid: 22523314
references.citation: Pediatr Cardiol. 2006 Mar-Apr;27(2):191-8
references.pmid: 16261271
references.citation: N Engl J Med. 2010 May 27;362(21):1980-92
references.pmid: 20505177
references.citation: J Am Coll Cardiol. 2001 Jun 1;37(7):1813-9
references.pmid: 11401116
references.citation: J Thorac Cardiovasc Surg. 2003 Aug;126(2):504-9; discussion 509-10
references.pmid: 12928651
references.citation: J Am Soc Echocardiogr. 2007 Dec;20(12):1364-73
references.pmid: 17604955
references.citation: Am J Cardiol. 2006 Jan 1;97(1):101-5
references.pmid: 16377292
references.citation: N Engl J Med. 1983 Jan 6;308(1):23-6
references.pmid: 6847920
references.citation: J Thorac Cardiovasc Surg. 2012 Oct;144(4):896-906
references.pmid: 22795436
references.citation: Circulation. 1970 Sep;42(3):455-62
references.pmid: 5451230