Original article
Cardiovascular
Mixed Venous Oxygen Saturation Monitoring After Stage 1 Palliation for Hypoplastic Left Heart Syndrome

Presented at the Forty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 29–31, 2007.
https://doi.org/10.1016/j.athoracsur.2007.05.047Get rights and content

Background

Staged palliation for hypoplastic left heart syndrome has been marked by high early mortality due to the limited cardiac output of the postischemic single right ventricle combined with the inefficiency and volatility of parallel circulation.

Methods

Since July 1996, we have performed stage 1 palliation (S1P) in 178 patients. Within this group is a consecutive cohort of 116 patients with true hypoplastic left heart syndrome that underwent S1P with a modified Blalock-Taussig shunt. A prospective database containing postoperative hemodynamic data was maintained on all patients. Studied were the incidence of organ failure, extracorporeal membrane oxygenation (ECMO), and mortality, as well as the relationship between these outcomes and postoperative hemodynamics.

Results

Hospital survival for this cohort was 93% (108/116). Patients who died after S1P had a lower superior vena cava oxygen saturation (Svo2) level compared with survivors (53.1% ±10.6% versus 59.3% ±9.2%, p = 0.034). Renal failure developed in 2 (1.7%) of the 116 patients, necrotizing enterocolitis developed in 1 (0.9%), and 5 (4.3%) had clinical seizures. ECMO support was instituted in 12 patients (10.3%). The Svo2 level was lower in patients requiring ECMO (54.0% ± 9.7% versus 59.9% ± 9.2%, p = 0.031).

Conclusions

Goal-directed therapy with Svo2 as an indicator of systemic oxygen delivery is associated with excellent early survival and a low incidence of organ failure after S1P. Inability to optimize Svo2 in the early postoperative period is associated with an increased risk of organ failure, ECMO, and death.

Section snippets

Patients

As of June 2006, 178 consecutive patients represent a single-center, 10-year experience with staged palliation for all patients with hypoplastic left heart syndrome (HLHS) or other variants of congenital heart disease with systemic outflow obstruction. This time period represents the use of continuous Svo2 monitoring for the postoperative management of patients who underwent stage 1 palliation (S1P). As previously described, a 4F oximetric catheter (Abbot Laboratories, North Chicago, IL) was

Results

Aortic atresia was present in 68% of patients (79/116), with associated mitral valve atresia in 58 and a patent mitral valve in 21. Aortic stenosis occurred in 32% (37/116), and a restrictive ventricular septal defect was present in 11% of the patients (13/116) with aortic stenosis. The native ascending aorta measured 3.3 ± 1.5 mm, and 41% (48/116) had a native aortas of less than 2.5 mm. Boys comprised 65% of the patients (75/116), and 43% (75/116) were diagnosed in utero, with prenatal

Comment

The early postoperative period after the Norwood procedure is one of high risk due to the compounding of several physiologic vulnerabilities. The single right ventricle is an inferior power source further compromised by a recent period of ischemia and CPB. With limited cardiac output, precise partitioning of the pulmonary and systemic flow is necessary to achieve adequate tissue oxygen delivery. The combination of decreased cardiac output and the inherent inefficiencies of parallel circulation

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