Key result
Dynamic postoperative events drive ~17% mortality after Norwood palliation rather than baseline characteristics.
Why the study?
Post-Norwood mortality remains high and unpredictable, and current models for mortality do not incorporate interstage events.
Cohort (n=360)
Yes
Dynamic predicted mortality trajectories incorporating time-related postoperative events provide more accurate, individualized risk assessment for neonates after the Norwood operation compared to baseline characteristics alone.
May enable dynamic individualized prognostication after Norwood using postoperative events; leaves open prospective validation before practice change.
Objective: Post-Norwood mortality remains high and unpredictable. Current models for mortality do not incorporate interstage events. We sought to determine the association of time-related interstage events, along with (pre)operative characteristics, with death post-Norwood and subsequently predict individual mortality. Methods: From the Congenital Heart Surgeons' Society Critical Left Heart Obstruction cohort, 360 neonates underwent Norwood operations from 2005 to 2016. Risk of death post-Norwood was modeled using a novel application of parametric hazard analysis, in which baseline and operative characteristics and time-related adverse events, procedures, and repeated weight and arterial oxygen saturation measurements were considered. Individual predicted mortality trajectories that dynamically update (increase or decrease) over time were derived and plotted. Results: After the Norwood, 282 patients (78%) progressed to stage 2 palliation, 60 patients (17%) died, 5 patients (1%) underwent heart transplantation, and 13 patients (4%) were alive without transitioning to another end point. In total, 3052 postoperative events occurred and 963 measures of weight and oxygen saturation were obtained. Risk factors for death included resuscitated cardiac arrest, moderate or greater atrioventricular valve regurgitation, intracranial hemorrhage/stroke, sepsis, lower longitudinal oxygen saturation, readmission, smaller baseline aortic diameter, smaller baseline mitral valve z-score, and lower longitudinal weight. Each patient's predicted mortality trajectory varied as risk factors occurred over time. Groups with qualitatively similar mortality trajectories were noted. Conclusions: Risk of death post-Norwood is dynamic and most frequently associated with time-related postoperative events and measures, rather than baseline characteristics. Dynamic predicted mortality trajectories for individuals and their visualization represent a paradigm shift from population-derived insights to precision medicine at the patient level.
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Meza et al. (2023) conducted a cohort in Critical Left Heart Obstruction (n=360). Time-related postoperative events and clinical status changes vs. Baseline characteristics / absence of events was evaluated on All-cause mortality between the Norwood operation and stage 2 palliation. Post-Norwood mortality (17%) is dynamic and primarily driven by time-related postoperative events, such as resuscitated cardiac arrest and lower longitudinal oxygen saturation, rather than baseline characteristics.
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