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Improved interstage mortality with the modified Norwood procedure: a meta-analysis
Clifford L Cua1, Ravi R Thiagarajan, Roozbeh Taeed
1Department of Pediatrics, Division of Pediatric Cardiology, Columbus Children's Hospital, Columbus, Ohio 43205-2696, USA. cuac@pediatrics.ohio-state.edu
Background:
Modification of the Norwood procedure has been reported to improve immediate postoperative mortality compared with the classic Norwood. Interstage mortality has not been shown to be improved with the modified Norwood probably because of the small number of patients from each institution. The goal of this study was to determine if meta-analysis would provide sufficient data to prove statistical difference in interstage mortality for the modified Norwood procedure.
Methods:
PubMed was searched using six different terms individually for articles from January 2003 to October 2004. Manuscripts that compared the classic to modified Norwood were reviewed. Mantel-Haenszel analysis was used to evaluate the relationship between treatment method and mortality stratified across hospitals. The Breslow-Day procedure tested homogeneity of odds ratio across hospitals. Separate analyses were performed for inpatient and interstage periods.
Results:
A total of 4,545 citations was screened. Five manuscripts met the criteria. Seventy-two patients undergoing classic Norwood and 84 patients undergoing modified Norwood survived to initial hospital discharge. The Breslow-Day statistic supported homogeneity of odds ratios for survival across hospitals (chi2 = 2.09, df = 4, p = 0.72). Odds of interstage death was 11.6 times greater (2.2 to 62.1, 95% CI) for the classic Norwood compared with the modified Norwood procedure. This difference was statistically significant by the Mantel-Haenszel chi2 (11.0, p = 0.001). The Breslow-Day statistic supported homogeneity of the odds ratios across hospitals (chi2 = 3.1, df = 4, p = 0.53).
Conclusions:
The modified Norwood procedure has a significantly lower interstage mortality compared with the classic Norwood procedure. A large randomized study is needed to determine whether these results remain consistent.
Insights
The modified Norwood procedure significantly reduces interstage mortality compared to the classic Norwood procedure. This meta-analysis suggests a lower risk of death between surgical stages for infants undergoing the modified approach.
Area of Science:
- Cardiology
- Pediatric Surgery
- Medical Statistics
Background:
- The Norwood procedure is a critical intervention for infants with hypoplastic left heart syndrome.
- While modifications aim to improve outcomes, interstage mortality remains a concern.
- Previous studies lacked sufficient data to definitively assess interstage mortality differences between classic and modified Norwood procedures.
Purpose of the Study:
- To determine if a meta-analysis could provide sufficient statistical power to demonstrate a difference in interstage mortality between the classic and modified Norwood procedures.
- To evaluate the effectiveness of modified Norwood procedures in reducing interstage mortality.
Main Methods:
- A comprehensive literature search was conducted on PubMed for articles published between January 2003 and October 2004.
- Five relevant manuscripts comparing classic and modified Norwood procedures were selected for review.
- Mantel-Haenszel analysis and Breslow-Day tests were employed to assess mortality differences and homogeneity of odds ratios across hospitals.
Main Results:
- The meta-analysis included data on 72 patients (classic Norwood) and 84 patients (modified Norwood) surviving to hospital discharge.
- Interstage death odds were 11.6 times higher for the classic Norwood procedure compared to the modified approach (95% CI: 2.2 to 62.1).
- This difference in interstage mortality was statistically significant (Mantel-Haenszel chi2 = 11.0, p = 0.001).
Conclusions:
- The modified Norwood procedure is associated with a statistically significant reduction in interstage mortality.
- These findings highlight the potential benefit of the modified Norwood procedure in improving survival rates for complex congenital heart defects.
- Further large-scale randomized studies are recommended to confirm these significant findings.