title: Stage 1 hybrid palliation for hypoplastic left heart syndrome--assessment of contemporary patterns of use: an analysis of The Society of Thoracic Surgeons Congenital Heart Surgery Database.
abstract: OBJECTIVE
  Hybrid palliation is an alternative to Norwood stage 1 for the initial management of hypoplastic left heart syndrome. Contemporary multicenter hybrid use and institutional/patient factors associated with hybrid use relative to the Norwood have not been evaluated. We describe hybrid use in relation to institutional volume, patient factors, and short-term outcomes.
  
  
  METHODS
  Infants aged 60 days or less listed in The Society of Thoracic Surgeons Congenital Heart Surgery Database (2010-2012) undergoing initial palliation of hypoplastic left heart syndrome were included. Annual institutional hybrid use rates were calculated: [hybrid procedures/(Norwood + hybrid + transplant procedures)]. In-hospital outcomes for primary hybrid and primary Norwood were compared and stratified by high (defined as ≥50%) versus low (defined as ≤10%) institutional hybrid use.
  
  
  RESULTS
  Of 1728 patients (100 centers), most (n = 1496, 87%) underwent an index Norwood; 232 patients (13%) underwent an index hybrid procedure. Preoperative patient risk factors were more prevalent in patients undergoing the hybrid procedure. Only 13 of 100 institutions were high hybrid users, and these tended to have lower annual hypoplastic left heart syndrome index case volume. Unadjusted in-hospital mortality was higher for the hybrid compared with the Norwood procedure (30% vs 16%; P < .001). In-hospital mortality for the hybrid procedure was not associated with hybrid use (26% among institutions with low use vs 28% among institutions with high use). However, centers with high hybrid use had higher mortality after the Norwood (43%) compared with centers with low hybrid use (16%).
  
  
  CONCLUSIONS
  Few centers currently select the hybrid procedure for most infants with hypoplastic left heart syndrome. Although unadjusted in-hospital hybrid mortality is higher than Norwood mortality, potential risk factors are more prevalent among hybrid cases. Institutions with higher hybrid use have lower hypoplastic left heart syndrome case volume and higher Norwood mortality.
authors.affiliation: Division of Pediatric Cardiac Surgery, Benioff Children's Hospital, University of California San Francisco, San Francisco, Calif. Electronic address: tara.karamlou@ucsfmedctr.org.
authors.forename: Tara
authors.initials: T
authors.lastname: Karamlou
authors.affiliation: Division of Cardiovascular Surgery, The Children's Heart Clinic, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minn.
authors.forename: David
authors.initials: D
authors.lastname: Overman
authors.affiliation: Division of Pediatric Cardiology, Duke University Medical Center, Durham, NC.
authors.forename: Kevin D
authors.initials: KD
authors.lastname: Hill
authors.affiliation: Outcomes Research and Assessment Group, Duke Clinical Research Institute, Durham, NC.
authors.forename: Amelia
authors.initials: A
authors.lastname: Wallace
authors.affiliation: Department of Pediatrics, University of Michigan C. S. Mott Children's Hospital, Ann Arbor, Mich.
authors.forename: Sara K
authors.initials: SK
authors.lastname: Pasquali
authors.affiliation: Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.
authors.forename: Jeffrey P
authors.initials: JP
authors.lastname: Jacobs
authors.affiliation: Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Md.
authors.forename: Marshall L
authors.initials: ML
authors.lastname: Jacobs
authors.affiliation: Division of Pediatric Cardiac Surgery, Hospital for Sick Children, Toronto, Canada.
authors.forename: Christopher A
authors.initials: CA
authors.lastname: Caldarone
mesh_terms: D002170:Canada; D016208:Databases, Factual; D005260:Female; D016027:Heart Transplantation / Q000639:trends; D017052:Hospital Mortality / Q000639:trends; D061847:Hospitals, High-Volume / Q000639:trends; D061846:Hospitals, Low-Volume / Q000639:trends; D006801:Humans; D018636:Hypoplastic Left Heart Syndrome / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D007223:Infant; D007226:Infant Mortality / Q000639:trends; D007231:Infant, Newborn; D008297:Male; D058327:Norwood Procedures / Q000009:adverse effects / Q000401:mortality / Q000639:trends*; D010166:Palliative Care / Q000639:trends*; D011651:Pulmonary Artery / Q000503:physiopathology / Q000601:surgery*; D012307:Risk Factors; D012955:Societies, Medical; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States