A dynamic Norwood mortality estimation: Characterizing individual, updated, predicted mortality trajectories after the Norwood operationCentral MessagePerspective
James M. Meza, MD, MSc,
Eugene H. Blackstone, MD,
Madison B. Argo, MD,
Lucy Thuita, MS,
Ashley Lowry, MS, MEd,
Jeevanantham Rajeswaran, PhD,
Anusha Jegatheeswaran, MD, PhD,
Christopher A. Caldarone, MD,
James K. Kirklin, MD,
William M. DeCampli, MD, PhD,
Kamal Pourmoghadam, MD,
Peter J. Gruber, MD, PhD,
Brian W. McCrindle, MD, MPH
Affiliations
James M. Meza, MD, MSc
Division of Cardiothoracic and Thoracic Surgery, Duke University Medical Center, Durham, NC
Eugene H. Blackstone, MD
Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Lerner Research Institute, The Cleveland Clinic, Cleveland, Ohio
Madison B. Argo, MD
Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wis; Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
Lucy Thuita, MS
Department of Quantitative Health Sciences, Lerner Research Institute, The Cleveland Clinic, Cleveland, Ohio
Ashley Lowry, MS, MEd
Department of Quantitative Health Sciences, Lerner Research Institute, The Cleveland Clinic, Cleveland, Ohio
Jeevanantham Rajeswaran, PhD
Department of Quantitative Health Sciences, Lerner Research Institute, The Cleveland Clinic, Cleveland, Ohio
Anusha Jegatheeswaran, MD, PhD
Division of Cardiovascular Surgery, Great Ormond Street Hospital for Children, London, United Kingdom
Christopher A. Caldarone, MD
Division of Congenital Heart Surgery, Texas Children's Hospital, Houston, Tex
James K. Kirklin, MD
Division of Cardiothoracic Surgery, The University of Alabama at Birmingham, Birmingham, Ala
William M. DeCampli, MD, PhD
Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, Fla
Kamal Pourmoghadam, MD
Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, Fla
Peter J. Gruber, MD, PhD
Division of Cardiothoracic Surgery, Yale New Haven Children's Hospital, New Haven, Conn
Brian W. McCrindle, MD, MPH
Labatt Family Heart Center, The Hospital for Sick Children, Toronto, Ontario, Canada; Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada; Address for reprints: Brian W. McCrindle, MD, MPH, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada M5G 1X8.
Objective: Post-Norwood mortality remains high and unpredictable. Current models for mortality do not incorporate interstage events. We sought to determine the association of time-related interstage events, along with (pre)operative characteristics, with death post-Norwood and subsequently predict individual mortality. Methods: From the Congenital Heart Surgeons' Society Critical Left Heart Obstruction cohort, 360 neonates underwent Norwood operations from 2005 to 2016. Risk of death post-Norwood was modeled using a novel application of parametric hazard analysis, in which baseline and operative characteristics and time-related adverse events, procedures, and repeated weight and arterial oxygen saturation measurements were considered. Individual predicted mortality trajectories that dynamically update (increase or decrease) over time were derived and plotted. Results: After the Norwood, 282 patients (78%) progressed to stage 2 palliation, 60 patients (17%) died, 5 patients (1%) underwent heart transplantation, and 13 patients (4%) were alive without transitioning to another end point. In total, 3052 postoperative events occurred and 963 measures of weight and oxygen saturation were obtained. Risk factors for death included resuscitated cardiac arrest, moderate or greater atrioventricular valve regurgitation, intracranial hemorrhage/stroke, sepsis, lower longitudinal oxygen saturation, readmission, smaller baseline aortic diameter, smaller baseline mitral valve z-score, and lower longitudinal weight. Each patient's predicted mortality trajectory varied as risk factors occurred over time. Groups with qualitatively similar mortality trajectories were noted. Conclusions: Risk of death post-Norwood is dynamic and most frequently associated with time-related postoperative events and measures, rather than baseline characteristics. Dynamic predicted mortality trajectories for individuals and their visualization represent a paradigm shift from population-derived insights to precision medicine at the patient level.
