Intervention for arch obstruction after the Norwood procedure: Prevalence, associated factors, and practice variability.
OBJECTIVE
Arch obstruction after the Norwood procedure is common and contributes to mortality. We determined the prevalence, associated factors, and practice variability of arch reintervention and assessed whether arch reintervention is associated with mortality.


METHODS
From 2005 to 2017, 593 neonates in the Congenital Heart Surgeons' Society Critical Left Heart Obstruction cohort underwent a Norwood procedure. Median follow-up was 3.7 years. Multivariable parametric models, including a modulated renewal analysis, were performed.


RESULTS
Of the 593 neonates, 146 (25%) underwent 218 reinterventions for arch obstruction after the Norwood procedure: catheter-based (n = 168) or surgical (n = 50) at a median age of 4.3 months (quartile 1-quartile 3, 2.6-5.7). Interdigitation of the distal aortic anastomosis was protective against arch reintervention. Development of ≥ moderate tricuspid valve regurgitation and right ventricular dysfunction at any point was associated with arch reintervention. Nonsignificant variables for arch reintervention included shunt type and preoperative aortic measurements. Surgical arch reintervention was protective against arch reintervention, but transcatheter reintervention was associated with increased reintervention. Arch reintervention was not associated with increased mortality. There was wide institutional variation in incidence of arch reintervention (range, 0-40 reinterventions per 100 years patient follow-up) and in preintervention gradient (range, 0-64 mm Hg).


CONCLUSIONS
Interdigitation of the distal aortic anastomosis during the Norwood procedure decreased the risk of arch reintervention. Surgical arch reintervention is more definitive than transcatheter. Arch reintervention after the Norwood procedure is not associated with increased mortality. Serial surveillance for arch obstruction, integrated with changes in right ventricular function and tricuspid valve regurgitation, is recommended after the Norwood procedure to improve outcomes.
['Devlin|Paul J|PJ|', 'McCrindle|Brian W|BW|', 'Kirklin|James K|JK|', 'Blackstone|Eugene H|EH|', 'DeCampli|William M|WM|', 'Caldarone|Christopher A|CA|', 'Dodge-Khatami|Ali|A|', 'Eghtesady|Pirooz|P|', 'Meza|James M|JM|', 'Gruber|Peter J|PJ|', 'Guleserian|Kristine J|KJ|', 'Alsoufi|Bahaaladin|B|', 'Lambert|Linda M|LM|', "O'Brien|James E|JE|", 'Austin|Erle H|EH|', 'Jacobs|Jeffrey P|JP|', 'Karamlou|Tara|T|']
D001018:Aortic Diseases D001157:Arterial Occlusive Diseases D005260:Female D006330:Heart Defects, Congenital D006439:Hemodynamics D006801:Humans D007223:Infant D007231:Infant, Newborn D008297:Male D058327:Norwood Procedures D015995:Prevalence D011446:Prospective Studies D020127:Recovery of Function D012086:Reoperation D018570:Risk Assessment D012307:Risk Factors D013997:Time Factors D016896:Treatment Outcome
arch obstruction Norwood critical left heart obstruction interdigitation coarctation hypoplastic left heart syndrome neoaorta