title: Second stage after initial hybrid palliation for hypoplastic left heart syndrome: Arterial or venous shunt?
abstract: OBJECTIVE
  Hybrid palliation for hypoplastic left heart syndrome has been developed as an alternative to neonatal Norwood surgery. At the second stage, a source of pulmonary blood flow has to be established. Options include an arterial modified Blalock-Taussig or a venous superior cavopulmonary shunt.
  
  
  METHODS
  We retrospectively reviewed patients who received second-stage palliation after the initial hybrid. Patients were stratified according to the source of pulmonary blood supply into the arterial shunt (n = 17 patients) or venous shunt (n = 26 patients).
  
  
  RESULTS
  Age and weight at second stage were lower in the arterial group (85 [45-268] days vs 152.5 [61-496] days, P = .001 and 3.6 [2.7-9.4] kg vs 5.1 [2.97-9.4] kg, P = .001, respectively). All recorded surgical times were shorter in the arterial group. Mechanical ventilation and intensive care stay were shorter in the venous group (5.82 [2.01-14.9] days vs 2.42 [0.56-13.67] days, P = .005 and 8.5 [3.6-23.7] vs 5.75 [0.8-17.6] days, P = .036, respectively) There was no difference in mortality (2/17 vs 5/26; P = .685) or incidence of complications between the 2 groups. There was a tendency toward a higher need for intervention in the immediate postoperative period in the venous group, but this did not reach significance (6/17 vs 13/26, P = .342). The arterial group has shown better development of the branch pulmonary arteries with a higher lower lobe index (158.38 ± 39.43 mm(2)/m(2) vs 113.33 ± 43.96 mm(2)/m(2), respectively, P = .037).
  
  
  CONCLUSIONS
  Both arterial and venous shunts are viable options with mortality and morbidity results comparable to those in the literature. The arterial shunt pathway (2-stage Norwood I) may offer better pulmonary arterial growth than the venous shunt (comprehensive/combined Norwood I and II).
authors.affiliation: Department of Cardiovascular Imaging, Division of Imaging Sciences and Biomedical Engineering, King's College, London, United Kingdom; Evelina London Children Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Department of Cardiothoracic Surgery, Alexandria University, Alexandria, Egypt. Electronic address: dinassar@yahoo.com.
authors.forename: Mohamed S
authors.initials: MS
authors.lastname: Nassar
authors.affiliation: Evelina London Children Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
authors.forename: Srinivas A
authors.initials: SA
authors.lastname: Narayan
authors.affiliation: Evelina London Children Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
authors.forename: Andrew
authors.initials: A
authors.lastname: Nyman
authors.affiliation: Evelina London Children Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
authors.forename: Caner
authors.initials: C
authors.lastname: Salih
authors.affiliation: Evelina London Children Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
authors.forename: Conal B
authors.initials: CB
authors.lastname: Austin
authors.affiliation: Department of Cardiovascular Imaging, Division of Imaging Sciences and Biomedical Engineering, King's College, London, United Kingdom; Evelina London Children Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
authors.forename: David
authors.initials: D
authors.lastname: Anderson
authors.affiliation: Department of Cardiovascular Imaging, Division of Imaging Sciences and Biomedical Engineering, King's College, London, United Kingdom; Evelina London Children Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
authors.forename: Tarique
authors.initials: T
authors.lastname: Hussain
mesh_terms: D058366:Blalock-Taussig Procedure / Q000009:adverse effects / Q000401:mortality; D016208:Databases, Factual; D018729:Fontan Procedure; D018610:Heart Bypass, Right / Q000009:adverse effects / Q000401:mortality; D006801:Humans; D018636:Hypoplastic Left Heart Syndrome / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D007223:Infant; D007902:Length of Stay; D008131:London; D061646:Operative Time; D010166:Palliative Care; D011183:Postoperative Complications / Q000401:mortality / Q000628:therapy; D011651:Pulmonary Artery / Q000503:physiopathology / Q000601:surgery*; D011652:Pulmonary Circulation; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D014683:Vena Cava, Superior / Q000503:physiopathology / Q000601:surgery*
keywords: Hypoplastic left heart syndrome; hybrid; shunt