Commentary: Everyone deserves a second chance

Abstract

Central MessageEarly identification of deviation from an expected pathway is key to improving Norwood outcomes.See Article page XXX. Early identification of deviation from an expected pathway is key to improving Norwood outcomes. See Article page XXX. Sengupta and colleagues1Sengupta A. Gauvreau K. Kaza A. Hoganson D. del Nido P.J. Nathan M. Timing of reintervention influences survival and resource utilization following first stage palliation of single ventricle heart disease.J Thorac Cardiovasc Surg. May 15, 2022; ([Epub ahead of print])Abstract Full Text PDF Google Scholar from Boston Children's Hospital provide a data-driven argument for the proactive surveillance of patients who are not performing to expectations, demonstrating improved outcomes in those who have early correction of residual lesions. In the Norwood operation, 3 elements need to be satisfactory—the aortic arch, the Damus connection, and the source of pulmonary blood flow. In this series, 18% had 1 or more problems at a range of postoperative time points. Strikingly, the presence of a residual or new lesion escalated the risk of mortality or transplant to approximately 20%, whereas later identification was associated with a far greater risk. The merits of early intervention are intuitively correct, and as a concept, early intervention is not likely to be controversial. Indeed, the approach is generalizable to other conditions, particularly neonatal interventions in which multipart reconstruction is required and uncommon operations in patients of all ages. In this study, the outcome data are analyzed as a continuous variable; it is not obvious if or when, in the first week after Norwood surgery, consideration of further investigations and intervention should occur in those who do not progress as expected. Interpretation is further complicated by the inclusion of both residual lesions such as fixed limitations of pulmonary blood flow, as well as evolving concerns such as progressive narrowing of the distal aortic arch. A logical extension of this work is the identification of a threshold time point at which a cascade of investigations is initiated. Excluding residual concerns is sometimes as important as identifying problems. In the postoperative management of neonatal cardiac surgery, it is a helpful and powerful strategy to communicate confidence in the technical aspects of the operation. This message allows the intensive care staff to progress the patient, to avoid overly cautious management that may increase the risk of complications related to prolonged ventilation and the use of muscle relaxants and sedation agents. Nothing is for free. There are of course negative consequences of invasive evaluation, particularly of cardiac catheterization. Risks associated with interventions to address lesions are also associated with substantial risk. Nevertheless, failure to perform an angiogram and reliance on suboptimal noninvasive imaging, particularly of pulmonary arteries in the Norwood context, also has an opportunity cost. Patients requiring extracorporeal membrane oxygenation were not included in this study. The need for extracorporeal membrane oxygenation is a strong predictor of residual or new lesions and in our practice is a trigger to exclude residual lesions. Whilst I understand the author's focus on residual lesions in the Norwood subparts, rather than isolated myocardial dysfunction, this patient group should be considered in extensions of this work. Full participation in this approach requires openness to the possibility that our technical work may not be optimal. The operating surgeon will have a good understanding of the likelihood that there is a technical problem, and in a Norwood patient, which of the 3 parts is likely to be a problem. Let's label it a nagging suspicion. Effective teamwork involves open communication from the surgeon and sharing of specific concerns, and codification of the process may facilitate this. Conventional wisdom says that in Norwood surgery you only have one opportunity to get the circulation correct. On the basis of this work, second chances do exist and all may end well if taken early. Timing of Reintervention Influences Survival and Resource Utilization Following First-Stage Palliation of Single Ventricle Heart DiseaseThe Journal of Thoracic and Cardiovascular SurgeryPreviewOutcomes following first-stage palliation of single-ventricle heart disease are influenced by many factors, including the presence of residual lesions requiring reintervention. However, there is a dearth of information regarding the optimal timing of reintervention. We assessed if earlier reintervention would be favorably associated with in-hospital outcomes among patients requiring unplanned reinterventions following the Norwood operation. Full-Text PDF