Predictors of Hospital LOS After Stage 2 Palliation for HLHS

Study Questions:

What factors are associated with prolonged hospital length of stay (LOS) following stage 2 palliation (S2P) for hypoplastic left heart syndrome (HLHS)?

Methods:

The National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) database, established in 2006, was queried. This registry includes patients from 44 US centers with HLHS who had undergone a Norwood-type palliation and were subsequently discharged home. Patients who had undergone a stage 1 hybrid procedure were excluded from this retrospective study.

Results:

There were 448 patients who had undergone S2P between 2008-2012. Of these, 57% were between 4-6 months old, with a median weight of 6 kg, a median LOS of 8 days, and a median intensive care unit (ICU) stay of 4 days. By univariate analysis, age outside of the 4-6 month range, a major extracardiac anomaly, a smaller center volume, a breathing-related concern or need for diuretics during interstage monitoring, daily outpatient surveillance of weight or oxygen saturation, need for additional procedures during S2P (atrial septectomy, atrioventricular [AV] valve repair, pulmonary artery [PA] plasty, but NOT aortic arch repair), postoperative need for vasoactive drugs, ICU readmission after transfer to the ward, and need for postoperative procedures (pericardiocentesis or thoracentesis, cardioversion, tracheostomy) were associated with a prolonged LOS. The type of Norwood I procedure (Blalock-Taussig shunt vs. right ventricle-PA conduit), impaired interstage weight gain, or pre-Glenn saturation <75% did not significantly increase LOS. By multivariate analysis, only the following variables were predictive of prolonged LOS: 1) the need for re-intervention after S2P, 2) nonoral methods of nutrition, and 3) postoperative complications (seizures, need for pacing or dialysis, infection, or vocal cord injury).

Conclusions:

Factors related to postoperative management after S2P, and not preoperative variables, are the most important predictors of LOS in patients with HLHS.

Perspective:

This is an important study that includes a large number of patients from many US institutions. Interestingly, daily surveillance was associated with a prolonged LOS, probably reflecting higher-risk patients. Interstage weight gain impairment and oxygen saturations of <75%, the very variables monitored in the home surveillance program, which had been touted to decrease interstage mortality, did not affect S2P LOS. Knowing which factors increase LOS may improve resource utilization and improve outcomes. Of note is that the NPC-QIC registry excludes patients who have remained hospitalized between stage 1 and S2P.

Clinical Topics: Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Pericardial Disease, Cardiac Surgery and CHD & Pediatrics, Congenital Heart Disease, CHD & Pediatrics and Interventions, CHD & Pediatrics and Quality Improvement, Interventions and Structural Heart Disease

Keywords: Blalock-Taussig Procedure, Cardiac Surgical Procedures, Fontan Procedure, Heart Defects, Congenital, Hypoplastic Left Heart Syndrome, Length of Stay, Norwood Procedures, Pericardiocentesis, Postoperative Complications, Quality Improvement


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