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Evolution Of The Norwood Operation Outcomes In Patients With Late Presentation
Osman O. Al-Radi, MBBCh, MSC, FRCSC1, Mohamed F. Ismail2, Ahmed F. Elamhrouk2, Amr Arafat1, Tamer E. Hamouda2, Bayan A. Alsheikh2, Mohamed S. Shihata, FRCSC2, Ahmed A. Jamjoom, FRCSC2.
1King Abdulaziz University, Jeddah, Saudi Arabia, 2King Faisal Specialist Hospital and Research Ceneter, Jeddah, Saudi Arabia.

Objectives: We present the evolution of Norwood operation outcomes and practice changes over a 15-year period from a single institution in Saudi Arabia. We intended to identify time-trends in shunt selection, procedural details and outcome predictors over time. Methods: Patients who underwent a Norwood operation (n= 145) between 2003 and 2018 with the use of a Blalock-Taussig shunt (BT group; n= 72), Right Ventricle to Pulmonary Artery shunt (Sano group; n= 66), or a primary Cavo-pulmonary shunt (CPS group; n=7), were included. The study outcomes were operative mortality, long-term survival and multistate transition to CPS, Fontan, and death. Results: Median age was 29 days. Predictors of operative mortality were lower weight (p= 0.026), and longer bypass time (p= 0.014), whereas, age and type of shunt were not. Predictors of improved long-term survival were higher weight at operation (p=0.0016), later time era (p=0.006) and shorter bypass time (p=0.001). The multistate model revealed that lower weight patients were more likely to undergo Sano vs. BT (p <0.001), and if BT was chosen in such patients they were more likely to die (p =0.027). The likelihood of receiving Sano shunt was three-fold higher in the recent era (p= 0.003). Conclusions: Improved outcomes of the Norwood operation are evident in the recent time era and with Sano shunt especially in smaller weight patients. Late presentation or older age is not a contraindication to Norwood operation. The incorporation of a primary CPS at stage one operation is feasible in selected patients.