Tadphale and colleagues [1Tadphale S.D. Tang X. ElHassan N.O. Beam B. Prodhan P. Cavopulmonary anastomosis during same hospitalization as stage 1 Norwood/hybrid palliative surgery.Ann Thorac Surg. 2017; 103: 1285-1292Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar] describe patient characteristics and outcomes associated with progression to stage 2 superior cavopulmonary anastomosis (SCPA) during the initial stage 1 hospitalization for patients with hypoplastic left heart syndrome. Although limited by the restraints of an administrative database, the report offers several interesting findings. Not unexpectedly, stage 1 patients who remained hospitalized until stage 2 (SCPA group) differed from those who were discharged or died (No SCPA group). Although some baseline characteristics suggested more innate comorbidities (e.g., birth weight, chromosomal abnormalities) for the SCPA group, these factors showed minimal significance on multivariate analysis. However, other multivariate markers for SCPA patients clearly portrayed a worse stage 1 postoperative course with more complications (e.g., necrotizing enterocolitis, septicemia) and more interventions (e.g., cardiopulmonary resuscitation [CPR], extracorporeal membrane oxygenation). Although SCPA patients were not shown to be at greater initial risk (sicker before stage 1), they apparently endured a more challenging recovery (sicker after stage 1). Patients with a right ventricle-to-pulmonary artery shunt were less likely to remain hospitalized until stage 2 than were those with a modified Blalock-Taussig shunt (MBTS). The single ventricle reconstruction trial demonstrated a higher incidence of CPR associated with the MBTS [2Ohye R.G. Sleeper L.A. Mahony L. et al.Comparison of shunt types in the Norwood procedure for single-ventricle lesions.N Engl J Med. 2010; 362: 1980-1992Crossref PubMed Scopus (682) Google Scholar]. In the present study, both MBTS use and need for CPR were identified as independent risk factors for same-hospitalization stage 2. Alternatively, right ventricle-to-pulmonary artery shunt use was associated with a decreased rate of inpatient stage 2 surgery, presumptively because of an improved postoperative course. It is important not to misinterpret the seemingly equivalent survival for the study groups. At first glance, it may appear that patients who underwent both stage 1 and 2 operations in the same hospitalization did not experience increased mortality attributable to the second operation. However, all the stage 1 inpatient deaths occurring before stage 2 were assigned to the No SCPA group, and all the SCPA patients were, by definition, stage 1 survivors. Accordingly, the mortality rate for the SCPA group (16%) entirely reflects inpatient deaths after the stage 2, and is notably higher than reported mortality for elective stage 2 surgery (1.1%–4.7%) [3Lee T.M. Aiyagari R. Hirsch J.C. Ohye R.G. Bove E.L. Devaney E.J. Risk factor analysis for second-stage palliation of single ventricle anatomy.Ann Thorac Surg. 2012; 93: 614-619Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar, 4Schwartz S.M. Lu M. Ohye R.G. et al.Risk factors for prolonged length of stay after the stage 2 procedure in the single-ventricle reconstruction trial.J Thorac Cardiovasc Surg. 2014; 147: 1791-1798Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 5Hill G.D. Rudd N.A. Ghanayem N.S. Hehir D.A. Bartz P.J. Center variability in timing of stage 2 palliation and association with interstage mortality: a report from the National Pediatric Cardiology Quality Improvement Collaborative.Pediatr Cardiol. 2016; 37: 1516-1524Crossref PubMed Scopus (22) Google Scholar]. The rate of same-hospitalization stage 1 and stage 2 surgery increased over time. With improvements in technique and management, some high-risk patients who may have previously succumbed may have achieved early hospital survival yet remained unable to be discharged. This fraction of high-risk survivors may have contributed to the higher rate of inpatient SCPA seen later in the study. In addition, with greater attention to the dangers of the out-of-hospital interstage, some centers may have reduced their threshold for proceeding with inpatient stage 2 palliation. Prospective studies are needed to determine the optimal management strategy for patients with prolonged hospitalization following stage 1 palliation. Reminiscent of the situation with low-birthweight newborns needing heart surgery, the dilemma faced may ultimately be a choice between protracted inpatient medical management (with its attendant morbidity) and early surgery (with the risks of decreased age, size, and perhaps suboptimal physiology). Cavopulmonary Anastomosis During Same Hospitalization as Stage 1 Norwood/Hybrid Palliative SurgeryThe Annals of Thoracic SurgeryVol. 103Issue 4PreviewLimited literature has examined characteristics of infants with hypoplastic left heart syndrome (HLHS) who remain hospitalized during the interstage period. We described their epidemiologic characteristics, in-hospital outcomes, and identified risk factors that predict the need for superior cavopulmonary anastomosis (SCPA) during the same hospitalization. Full-Text PDF