title: Older age at the time of the Norwood procedure is a risk factor for early postoperative mortality†.
abstract: OBJECTIVE
  The Norwood procedure is commonly used as first-step palliation in children with hypoplastic left heart syndrome or related congenital malformations. In most cases, the operation is carried out during the first week of life. Excessive pulmonary blood flow in univentricular physiology can soon lead to compromised cardiac function and pulmonary hypertension and could have an influence on postoperative outcomes.
  
  
  METHODS
  Between 1997 and 2011, 257 Norwood procedures were performed at the Kinderherz-Zentrum Linz. Twenty-seven patients were older than 20 days at the time of the Norwood operation without previous pulmonary artery banding. A retrospective analysis of the two age groups was carried out concerning early mortality, interstage mortality and major events until the bidirectional Glenn operation.
  
  
  RESULTS
  Patients older than 20 days had a significantly higher mortality rate before the bidirectional Glenn operation than younger patients (44.4 vs 20.3%; P = 0.002). They also showed a significantly higher need for postoperative inhalative nitric oxide therapy (40.7 vs 14.5%, P = 0.002). Summarized risk for either successful postoperative cardiopulmonary resuscitation (CPR), extracorporeal membrane oxygenation therapy or mortality before the bidirectional Glenn operation was 59.3% in the older age group vs 23.8% in the younger age group (P < 0.001).
  
  
  CONCLUSIONS
  Age older than 20 days seems to be an independent risk factor for early postoperative mortality and fatal events after the Norwood procedure. Long-persisting excessive pulmonary blood flow and preoperative cardiac decompensation can be the reason for postoperative lethal pulmonary hypertensive crisis and compromised ventricular function.
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, General Hospital Linz, Linz, Austria eva.sames-dolzer@akh.linz.at.
authors.forename: Eva
authors.initials: E
authors.lastname: Sames-Dolzer
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, General Hospital Linz, Linz, Austria.
authors.forename: Lale
authors.initials: L
authors.lastname: Hakami
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, General Hospital Linz, Linz, Austria.
authors.forename: Michaela
authors.initials: M
authors.lastname: Innerhuber
authors.affiliation: Department of Pediatric Cardiology, Children's Hospital Linz, Linz, Austria.
authors.forename: Gerald
authors.initials: G
authors.lastname: Tulzer
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, General Hospital Linz, Linz, Austria.
authors.forename: Rudolf
authors.initials: R
authors.lastname: Mair
mesh_terms: D015199:Extracorporeal Membrane Oxygenation; D005260:Female; D006801:Humans; D018636:Hypoplastic Left Heart Syndrome / Q000601:surgery; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D058327:Norwood Procedures / Q000009:adverse effects* / Q000379:methods / Q000401:mortality* / Q000706:statistics & numerical data; D011183:Postoperative Complications; D012189:Retrospective Studies; D012307:Risk Factors
keywords: Hypoplastic left heart syndrome; Norwood procedures; Risk factors