title: Introduction to a Norwood program in an emerging economy: learning curve of a single center.
abstract: BACKGROUND
  There has been a notable improvement in the outcome of stage 1 palliation for hypoplastic left heart syndrome (HLHS) in recent years. Nevertheless, developing a new Norwood program requires a steep learning curve, especially in emerging economies where rapid population growth brings a high volume of patients but, on the other hand, resources are limited. In this paper we aimed to summarize the initial results of a single center.
  
  
  METHODS
  Hospital records of 21 patients were reviewed for all patients having a stage 1 palliation procedure for HLHS between May 2011 and May 2013. There were 13 male (62%) and 8 female (38%) patients. Median age was 14 days (range, 4-74 days) and median weight was 3030 g (2600-3900 g). HLHS was defined as mitral or aortic stenosis or atresia (or both) in the presence of normally related great vessels and a hypoplastic left ventricle. Transthoracic echocardiography was the diagnostic modality used in all patients. All procedures but one were performed using an antegrade selective cerebral perfusion method and moderate hypothermia. Cerebral perfusion was monitored with cerebral oximetry in all patients. Modified ultrafiltration was routinely used in all patients.
  
  
  RESULTS
  Overall hospital mortality was 47.6% (n = 10). Mortality rates considerably decreased from the first year to second year (69% and 12.5% respectively). No risk factors were identified for mortality.
  
  
  CONCLUSIONS
  Surgical palliation of neonates with hypoplastic left heart syndrome continues to be a challenge. To decrease the overall mortality nationwide and improve outcomes, a referral center with a dedicated team is necessary in emerging economies.
authors.affiliation: Department of Pediatric Cardiac Surgery, Kosuyolu Heart Center, Istanbul, Turkey.
authors.forename: Murat
authors.initials: M
authors.lastname: Başaran
authors.affiliation: Department of Pediatric Cardiac Surgery, Kosuyolu Heart Center, Istanbul, Turkey.
authors.forename: Eylem
authors.initials: E
authors.lastname: Tunçer
authors.affiliation: Department of Anesthesiology and Reanimation, Kosuyolu Heart Center, Istanbul, Turkey.
authors.forename: Füsun
authors.initials: F
authors.lastname: Güzelmeriç
authors.affiliation: Department of Pediatric Cardiac Surgery, Kosuyolu Heart Center, Istanbul, Turkey.
authors.forename: Nihat
authors.initials: N
authors.lastname: Cine
authors.affiliation: Department of Pediatric Cardiology, Kosuyolu Heart Center, Istanbul, Turkey.
authors.forename: Naci
authors.initials: N
authors.lastname: Oner
authors.affiliation: Department of Pediatric Cardiology, Kosuyolu Heart Center, Istanbul, Turkey.
authors.forename: Ayşe
authors.initials: A
authors.lastname: Yildirim
authors.affiliation: Department of Anesthesiology and Reanimation, Kosuyolu Heart Center, Istanbul, Turkey.
authors.forename: Omer
authors.initials: O
authors.lastname: Savluk
authors.affiliation: Department of Pediatric Cardiac Surgery, Kosuyolu Heart Center, Istanbul, Turkey.
authors.forename: Behzat
authors.initials: B
authors.lastname: Tüzün
authors.affiliation: Department of Pediatric Cardiac Surgery, Kosuyolu Heart Center, Istanbul, Turkey.
authors.forename: Hakan
authors.initials: H
authors.lastname: Ceyran
mesh_terms: D006348:Cardiac Surgical Procedures / Q000191:economics; D003906:Developing Countries; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D018636:Hypoplastic Left Heart Syndrome / Q000175:diagnosis / Q000191:economics / Q000401:mortality / Q000628:therapy*; D007223:Infant; D007231:Infant, Newborn; D059032:Learning Curve; D008297:Male; D010166:Palliative Care / Q000379:methods / Q000458:organization & administration*; D016730:Program Development; D065286:Prophylactic Surgical Procedures / Q000191:economics* / Q000379:methods; D016896:Treatment Outcome; D014421:Turkey