P0395 - Impact of Gastrostomy Tube and Nutritional Monitoring on Interstage Outcomes following Stage 1 Norwood Palliation

Objective: Stage I Norwood palliation (S1P) for functional single ventricle physiology carries a mortality risk of 15%, and patients remain at risk for adverse outcomes during the interstage period prior to second stage palliation (S2P). Feeding dysfunction (FD) is common in this population and may be associated with poorer outcomes. While there is wide institutional variation in nutritional management, there have been increasing efforts to ameliorate interstage mortality over the past decade emphasizing nutrition, feeding delivery, and home monitoring programs (HMPs). In 2009, we implemented an HMP, and by 2013, this included earlier consideration of gastrostomy tube (GT) placement for infants with identified FD. We aimed to characterize the impact of this strategy on interstage mortality and growth.

Methods: Patients who underwent S1P between 2008 and 2018 at our institution were retrospectively reviewed. Baseline demographics, operative characteristics, and outcomes during the interstage period were analyzed for the entire cohort; for patients with (GT) or without GT (nGT); and across three eras: I: 2008-2012; II: 2013-2016; III: 2017-2018.

Results: A total of 79 patients met inclusion criteria (50 GT, 29 nGT). Birth, S1P and S2P weight-for-age z-scores (WAZ) were similar across eras and between GT and nGT groups (Table 2). GT utilization increased from 50% (13/26) in Era I to 78% (14/18) in Era III. Overall interstage mortality was 3.8% (3/79) and did not vary by era or presence of GT. GT placement following S1P occurred at a median of 97.59 ± 53.46 days in Era I vs. 33.75 ± 17.12 days in era III (p<001). Weight gain doubled after GT placement (0.020 vs. 0.011 kg/d, p<0.05). The GT group was higher risk with more FD, preoperative risk factors (RF) (28% vs. 6.9% with ≥3 RFs, p=0.024), postoperative S1P complications (42% vs. 6.9% with ≥4, p=0.009), longer mechanical ventilation time, ECMO support for cardiac arrest, longer S1P LOS (60.4 vs. 32.6 days, p<<0.05), and shorter readmission time (Table 1). However, the GT group achieved a similar WAZ as the nGT group even though the interstage interval was shorter for the GT group in Era III (176.70 ± 46.39 vs 202.93 ± 53.75 days, p=0.019). 30-day and interstage hospital readmissions were similar between GT and nGT groups, but nGT had more readmissions for feeding difficulty (Table 1). There was only 1 readmission for a GT-related issue. Interstage emergency department visits did not differ between GT and nGT groups, and only 28.6% (24/84) of the visits were GT-related.

Conclusion: HMPs including aggressive GT consideration for high-risk patients with FD following S1P are associated with interstage growth and overall survival similar to lower-risk patients without FD. Additionally, GT utilization does not significantly increase interstage morbidity.