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J Thorac Cardiovasc Surg 2003;126:1367-1375
© 2003 The American Association for Thoracic Surgery

Surgery for congenital heart disease

Home surveillance program prevents interstage mortality after the Norwood procedure

^a Department of Pediatrics, Children’s Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wis, USA
^b Division of Critical Care, Children’s Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wis, USA
^c Division of Cardiology, Children’s Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wis, USA
^d Department of Anesthesia, Children’s Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wis, USA
^e Department of Surgery, Division of Cardiothoracic Surgery, Children’s Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wis, USA
^f National Outcomes Center, Inc, Children’s Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, WisUSA

Read at the Eighty-second Annual Meeting of The American Association for Thoracic Surgery, Washington, DC, May 5-8, 2002.

Received for publication May 4, 2002; accepted for publication November 5, 2002.

^* Address for reprints: Nancy S. Ghanayem, MD, Pediatric Critical Care, Children’s Hospital of Wisconsin, 9000 W Wisconsin Ave, Milwaukee, WI 53226, USA
nghanayem{at}aol.com

OBJECTIVE: To determine whether early identification of physiologic variances associated with interstage death would reduce mortality, we developed a home surveillance program.

METHODS: Patients discharged before initiation of home surveillance (group A, n = 63) were compared with patients discharged with an infant scale and pulse oximeter (group B, n = 24). Parents maintained a daily log of weight and arterial oxygen saturation according to pulse oximetry and were instructed to contact their physician in case of an arterial oxygen saturation less than 70% according to pulse oximetry, an acute weight loss of more than 30 g in 24 hours, or failure to gain at least 20 g during a 3-day period.

RESULTS: Interstage mortality among infants surviving to discharge was 15.8% (n = 9/57) in group A and 0% (n = 0/24) in group B (P = .039). Surveillance criteria were breached for 13 of 24 group B patients: 12 patients with decreased arterial oxygen saturation according to pulse oximetry with or without poor weight gain and 1 patient with poor weight gain alone. These 13 patients underwent bidirectional superior cavopulmonary connection (stage 2 palliation) at an earlier age, 3.7 ± 1.1 months of age versus 5.2 ± 2.0 months for patients with an uncomplicated interstage course (P = .028). A growth curve was generated and showed reduced growth velocity between 4 and 5 months of age, with a plateau in growth beyond 5 months of age.

CONCLUSION: Daily home surveillance of arterial oxygen saturation according to pulse oximetry and weight selected patients at increased risk of interstage death, permitting timely intervention, primarily with early stage 2 palliation, and was associated with improved interstage survival. Diminished growth identified 4 to 5 months after the Norwood procedure brings into question the value of delaying stage 2 palliation beyond 5 months of age.