Impact of home monitoring program on inter-stage mortality after the Norwood procedure

doi:10.21203/rs.3.rs-2963029/v1

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Impact of home monitoring program on inter-stage mortality after the Norwood procedure

https://doi.org/10.21203/rs.3.rs-2963029/v1

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Background

While early outcome after the Norwood operation for hypoplastic left heart syndrome has improved, inter-stage mortality until bidirectional cavopulmonary shunt (BCPS) remains a concern. Our aim was to institute a home monitoring program to (HMP) reduce inter-stage mortality.

Methods

Among 264 patients who survived Norwood procedure and were discharged before BCPS, 80 patients were included in the HMP and compared to the remaining 184 patients regarding inter-stage mortality. In patients with HMP, events during the inter-stage period were evaluated.

Results

Inter-stage mortality was 8% (n = 21) and was significantly lower in patients with HMP (2.5%, n = 2), compared to those without (10.3%, n = 19, p = 0.031). Patients with inter-stage mortality had significantly lower birth weight (p < 0.001) compared to those without. Lower birth weight (p < 0.001), extracorporeal membrane oxygenation support (p = 0.002), and lack of HMP (p = 0.048) were risk factors for inter-stage mortality. Most frequent event during home monitoring was low saturation (< 70%) in 14 patients (18%), followed by infection in 6 (7.5%), stagnant weight gain in 5 (6.3%), hypoxic shock in 3 (3.8%) and arrhythmia in 2 (2.5%). Unexpected readmission was needed in 24 patients (30%). In those patients, age (p = 0.001) and weight at BCPS (p = 0.007) were significantly lower compared to those without readmission, but the survival after BCPS was comparable between the groups.

Conclusions

Inter-stage HMP permits timely intervention and led to an important decrease in inter-stage mortality. One-third of the patients with home monitoring program needed readmission and demonstrated the need for earlier stage 2 palliation.

hypoplastic left heart syndrome

Norwood procedure

inter-stage home monitoring program

bidirectional cavopulmonary shunt

The neonatal Norwood procedure for hypoplastic left heart syndrome (HLHS) and its variant has undergone constant improvement and modification to archive best possible results [1, 2]. Nevertheless, the critical period does not end with the patients’ discharge from hospital but spans the inter-stage period. Various research has indicated that inter-stage mortality may range from 2% to as high as 20% [3–5]. Risk factors for adverse events during this period have been studied over the years. Many of these factors, such as low birth weight, anatomical subtypes or extra-cardiac anomalies, contribute to increased inter-stage mortality, but by their nature largely elude operative control [4, 6, 7]. Therefore, patients affected by these factors require close monitoring [6].

Common complications that may arise include excessive hypoxemia, hypovolemia, changes in systemic and pulmonary vascular resistance or progressive myocardial dysfunction [5, 8, 9]. Particularly, stenosis of the modified Blalock-Taussig shunt (MBTS) or right ventricle to pulmonary artery conduit (RVPAC) may disrupt the balance between systemic and pulmonary circulation [9]. Respiratory illnesses may also be a risk for inter-stage complications. Hence, our aim was to identify potentially critical courses before patients presented with fulminant complications. To extend the monitoring of key parameters beyond hospital discharge, we initiated a home monitoring program (HMP) according to the report by Ghanayem, et al [10]. HMP aims to detect critical changes, such as drop in oxygen saturation and decrease in weight gain. In addition, HMP serves to support parents and custodians in the care of critically ill children. Many studies have presented positive results in reducing inter-stage mortality by implementing similarly structured programs [10]. Rudd et al have reported excellent inter-stage survival rates of 98% following the introduction of their HMP [11].

This study intends to evaluate the following two points: 1) Whether the introduction of HMP reduced the inter-stage mortality after the Norwood procedure. 2) How the HMP identified patient problems and how it influenced outcomes after bidirectional cavopulmonary shunt (BCPS).

Ethical statement

This study was approved by the Institutional Review Board of the Technical University of Munich (approved number of 305/20 S-KH on 2 June, 2020). Because of its retrospective nature, the need for individual patient consent was waived.

Patients

Between January 2001 and December 2020, 335 consecutive patients with HLHS and its variants underwent the neonatal Norwood procedure at the German Heart Centre of Munich. Patients who were subsequently discharged from hospital with shunt-dependent physiology were included in this study (n=264). Patients who died in hospital and those who underwent BCPS following S1P without being discharged in the interim were excluded from the study (Figure 1).

Operative techniques

The Norwood procedure is performed under standard cardiopulmonary bypass (CPB) with hypothermic circulatory arrest. Selective cerebral perfusion has been performed since 2009. The details of the surgical techniques are described in our previous reports [12,13]. The choice of shunt was made at the discretion of patients’ surgeon and cardiologist. In patients who received RVPAC, a 5.0 mm ringed Gore-Tex graft was used in most patients. In patients who underwent MBTS, most patients received a 3.5 mm non-ringed Gore-Tex graft. All patients were admitted to the intensive care unit (ICU) postoperatively with an open chest. Delayed sternal closure was usually performed on the second postoperative day.

Home monitoring program

In 2013, an inter-stage HMP was established at our center, which allowed close monitoring and regular check-ups of the patients. Patients’ caregivers were instructed in measuring and documenting the patient’s daily percutaneous oxygen saturation (SpO2), heart rate, weight gain and feeding protocol at least twice a week. Surveillance criteria were measured using pulse oximeters and sensitive digital infant scales. Parents were informed that resting SpO2 less than 70%, weight loss of 30 g or failure to gain 20 g of weight for 3 days should be considered critical and that in the respective case a call to the hospital should be made [12]. Furthermore, parents received the usual discharge information to recognize warning signs of respiratory or gastrointestinal illness, respiratory distress, such as tachypnea and nasal flaring, or changes in perfusion. If problems arose, any necessary action was decided upon depending on the severity of the symptoms.

Identification of factors affecting mortality

Inter-stage mortality, defined as mortality between hospital discharge and BCPS, was analyzed using Cox-regression model. Pre-, intra- and postoperative variables were analyzed as risk factors.

Follow-up data

Apart from the HMP, all patients obtained outpatient follow-up with pediatric cardiologists. For patients who died, the endpoint of the survey was marked at the time of death. The follow-up data were regularly tracked and updated using our institutional single-ventricle database system.

Statistical analysis

Categorical variables are expressed as absolute numbers and percentages. Continuous variables are expressed as medians with interquartile ranges (IQR). An independent Student´s t-test was used to compare normally distributed variables. The Mann-Whitney U test was used for variables that were not normally distributed. Survival after hospital discharge and survival after BCPS was estimated by the Kaplan-Meier method. Risk factors for mortality were identified using univariate and multivariate Cox regression models. Weight fo age z-score (WAZ) was calculated using the WHO Anthro software 3.2. Data analysis was performed using SPSS version 25.0 for Windows (IBM, Ehningen, Germany) and R statistical software 4.2.1 (R Foundation for Statistical Computing).

Patients and outcomes after the Norwood procedure

Patients´ characteristics are shown in Table 1.

Table 1. Patient characteristics
Variables	Total	Inter-stage survivals	Inter-stage deaths	P value
	n=264 (%)	243 (92%)	21 (8%)
Male gender	182 (68.9)	169 (69.5)	13 (61.9)	0.468
Gestational age (weeks)	39 (38-40)	39 (28-40)	39 (37-39)	0.201
Birth weight (gram)	3.2 (2.9-3.5)	3.3 (2.9-3.6)	3.0 (2.2-3.2)	<0.001
Low birth weight (<2.5kg)	16 (6.3)	13 (5.5)	3 (16.7)	0.06
Genetic anomalies	11 (4.3)	11 (4.7)	0 (0)	0.32
Extracardiac anomalies	30 (11.8)	27 (11.5)	3 (15.0)	0.64
EFE	25 (9.7)	22 (9.3)	3 (14.3)	0.46
HLHS	217 (82.2)	200 (82.3)	17 (81.0)	0.877
AA/MA	50 (22.6)	46 (22.5)	4 (23.5)	0.926
AA/MS	57 (25.9)	52 (25.6)	5 (29.4)	0.731
AS/MA	26 (11.8)	24 (11.8)	2 (11.8)	0.994
AS/MS	88 (40.0)	82 (40.4)	6 (35.3)	0.680
Variant	47 (17.8)	43 (17.7)	4 (19.0)	0.877

Kg: Kilogram, EFE: Endocardial Fibroelastosis, HLHS: Hypoplastic left heart syndrome, AA: Aortic atresia, MA: Mitral atresia, MS: Mitral Stenosis, AS: Aortic stenosis

Median birth weight was 3.2 (2.9-3.5) kg and 16 (6.3%) patients had a birth weight of less than 2.5 kg. Main diagnosis included 217 HLHS (82.2%) and 47 variants (17.8%). In 217 patients with HLHS, anatomic subtypes included 50 aortic atresia (AA)/mitral atresia (MA), 57 AA/mitral stenosis (MS), 26 aortic stenosis (AS)/MA and 88 AS/MS. Genetic anomalies and extra-cardiac anomalies were observed in 11 (4.3%) and in 30 (11.8%) patients, respectively. Birth weight was significantly lower in patients with inter-stage deaths compared to those without inter-stage death (p<0.001). Other variables were similar between the two groups.

Operative and postoperative data are shown in Table 2.

Table 2. Operative- and Post-operative variables
Variables	Total	Inter-stage survivals	Inter-stage deaths	P value
	n=264 (%)	243 (92%)	21 (8%)
Age at Norwood	9 (7-12)	9 (7-11)	9 (7-13)	0.112
Weight at Norwood	3.2 (2.9-3.5)	3.2 (3.0-3.5)	3.1 (2.8-3.3)	0.008
CPB time	137 (104-159)	134 (102-159)	138 (122-175)	0.033
AXC time	48 (40-58)	48 (40-58)	46 (41-57)	0.388
RVPAS	131 (49.6)	124 (51.0)	7 (33.3)	0.120
Intubation	5 (4-8)	5 (4-7)	4 (3-11)	0.120
ICU stay	12 (8-20)	12 (8-19)	13 (7-13)	0.065
ECMO	11 (4.2)	7 (2.9)	4 (19.0)	<0.001
Re-OP after Norwood	68 (26.4)	61 (25.7)	7 (33.3)	0.449
Re-intubation	40 (15.6)	36 (15.3)	4 (19.0)	0.652
Shunt intervention	27 (10.4)	24 (10.0)	3 (14.3)	0.541
Re CoA intervention	9 (3.5)	8 (3.3)	1 (4.8)	0.734
PD	18 (7.0)	15 (6.4)	3 (14.3)	0.175
NEC	14 (5.5)	11 (4.7)	3 (14.3)	0.065
HSP stay	24 (16-35)	24 (16-35)	22 (15-61)	0.149
Age at discharge	35 (27-46)	35 (27-46)	36 (27-71)	0.069
Weight at discharge	3.2 (3.0-3.7)	3.3 (3.0-3.7)	3.1 (2.9-3.7)	0.184
SO2 at discharge	85 (80-87)	85 (80-87)	85 (80-85)	0.156
HMP possible	80 (30.3)	78 (32.1)	2 (9.5)	0.031

CPB: Cardiopulmonary Bypass, AXC: Aortic Cross Clamp; RVPAS: Right Ventricle to Pulmonary Artery Shunt, ICU: Intensive Care Unit, ECMO: Extracorporeal Membrane Oxygenation, CoA: Coarctation of Aorta, PD: Peritoneal Dialysis, NEC: Necrotizing Enterocolitis, HSP: Hospital, HMP: Home Monitoring Program

Median age and weight at the Norwood procedure were 9 (7-12) days and 3.2 (2.9-3.5) kg, respectively. As for shunt-types, MBTS was performed in 133 (50.4%) patients, and RVPAC in 131 (49.6%). Median age and weight at hospital discharge were 24 (16-35) days and 3.2 (3.0-3.7) kg, respectively. Patients with inter-stage death had lower weight at Norwood (p=0.008), longer CPB time (p=0.033), and higher incidence of extracorporeal membrane oxygen (ECMO) support (p<0.001), compared to patients without inter-stage death.

Inter-stage mortality

There were 21 inter-stage mortality between hospital discharge and BCPS. The cause of death was 12 heart failure, 4 sudden death, 2 progressive hypoxia, and 3 unclear cause of death. Since the introduction of HMP in our institute in 2013, 80 patients have been included. However, 71 patients could not receive HMP because they were not resident in Germany, or the patients’ condition could not be reported regularly for some reasons. The inter-stage mortality of patients who were included into the HMP (n=2, 2.5%) was lower than the mortality of patients without HMP (n=19, 11.6%, p=0.031). These results are depicted in Figure 2.

Lower birth weight (p<0.001), weight at Norwood (p=0.016), longer ICU stay (p=0.005), need for ECMO support (p=0.002) and lack of HMP (p=0.048) were identified as risk factors using univariable analysis. Multivariable analysis identified lower birth weight (p=0.003) as an independent risk factor. Risk factors for inter-stage death are shown in Table 3.

Table 3. Analysis of candidate risk factors for inter-stage mortality following the Norwood procedure
Variable	Univariable model			Multivariable model
	HR	(95% CI)	p value	HR	(95% CI)	p value
Birth related variables
Premature birth
Birth weight (per gram)	0.572	0.411-0.795	<0.001	0.998	0.997-0.999	0.003
Genetic anomalies	0.046	0.000-542.300	0.521
Extracardiac anomalies	1.299	0.381-4.433	0.676
HLHS	0.899	0.302-2.672	0.848
AA	1.517	0.644-3.573	0.340
MA	1.410	0.555-3.581	0.470
UAVSD	1.500	0.201-11.179	0.692
Reduced VF
AVVR pre Norwood	0.042	0.000-29.638	0.344
Restrictive ASD	0.979	0.395-2.425	0.963
Ao Asc. diameter	1.025	0.823-1.277	0.827
Norwood variables
Age at Norwood	1.048	0.974-1.128	0.210
Weight at Norwood	0.300	0.112-0.800	0.016
RVPAC	0.486	0.196-1.203	0.119
Postoperative variables
Intubation	1.025	0.985-1.066	0.220
ICU stay	1.018	1.005-1.031	0.005
HSP stay	1.011	0.997-1.025	0.132
ECMO	5.756	1.936-17.113	0.002	4.158	0.939-18.407	0.061
Re OP	1.393	0.562-3.452	0.474
Re Intubation	1.332	0.448-3.960	0.606
PD	2.146	0.632-7.286	0.221
NEC	3.140	0.925-10.664	0.067
Shunt intervention	1.407	0.414-4.777	0.584
Re-CoA intervention	1.387	0.186-10.337	0.749
Findings at discharge
Weight	1.000	0.999-1.001	0.349
Systolic Pressure	0.966	0.920-1.015	0.176
Diastolic Pressure	0.960	0.900-1.024	0.217
MAP	0.918	0.812-1.039	0.178
SO2	0.942	0.836-1.061	0.327
Heart rate	0.976	0.935-1.018	0.256
HMP (-)	4.347	1.014-18.867	0.048	3.460	0.771-14.705	0.103

HR: Hazard Ratio, CI: Confidence Interval, HLHS: Hypoplastic left heart syndrome, AA: Aortic atresia, MA: Mitral atresia, MS: Mitral Stenosis, AS: Aortic stenosis, UAVSD: Unbalanced Atrioventricular Septal Defect, VF: Ventricular Function, AVVR: Atrioventricular Valve Regurgitation; ASD: Atrial Septal Defect, Ao Asc: Ascending Aorta, RVPAS: Right Ventricle to Pulmonary Artery Shunt, ICU: Intensive Care Unit, HSP: Hospital, ECMO: Extracorporeal Membrane Oxygenation, PD: Peritoneal Dialysis, NEC: Necrotizing Enterocolitis, MAP: Mean Aterial Pressure, HMP: Home Monitoring Program

When we selected 151 patients who had undergone the Norwood procedure since 2013 and performed the same analysis, weight at Norwood (p=0.008), need for ECMO (p<0.001) and lack of HMP (p<0.001) were identified as independent risk factors (Supplementary Table S1).

Results of HMP

The events that occurred within the HMP during inter-stage period are shown in Table 4.

Table 4. Events of Home Monitoring Program (HMP)
Events	N (%) or median (IQR)
HMP patient number	80
Low SO2 <70%	14 (17,5)
Arrhythmia	2 (2.5)
Infection	6 (7.5)
Vaccination effect	2 (2.5)
Hypoxic schock	3 (3.8)
Stagnated weight gain	5 (6.3)
Readmission	24 (30.0)
Interval (days)	29 (18-54)

IQR: Interquartile Range; HMP: Home Monitoring Program

The most common event was low saturation (<70%) in 14 patients (18%), followed by infection (n=6, 7.5%), stagnated weight gain (n=5, 6.3%), hypoxic shock (n=3, 3.8%), arrhythmia (n=2, 2.5%) and vaccine side effects (n=2, 2.5%). Readmission to the hospital was required in 24 (30%) patients with a median 29 (18-54) days after the hospital discharge. No variable at hospital discharge was identified as a risk for readmission (Supplementary Table S2). Shunt-types showed no difference in the incidence of readmission (Supplementary Figure S1).

Characteristics at the time of BCPS

Characteristics at the time of BCPS in patients with and without HMP are shown in Table 5A.

Table 5. Characteristics at time of BCPS
A. Patients with and without HMP
Variables	All	HMP (+)	HMP (-)	p-value
N	228	157 (85.3)	71 (88.8)	0.456
Age at BCPS (months)	4.0 (3.2-5.0)	3.7 (3.0-4.6)	4.1 (3.3-5.3)	0.015
Weight at BCPS (kg)	5.1 (4.5-5.9)	5.0 (4.6-5.6)	5.2 (4.5-6.0)	0.298
Weight Z score	1.9 (2.7- 1.1)*	1.7 (2.4-0.9)	2.1 (2.8-1.2)	0.010
Mortality after BCPS	21 (8.0)	16 (8.7)	5 (6.3)	0.500

B. Patients with and without readmission during inter-stage
Variables	All	Re admission (+)	Re admission (-)	p-value
N	71	22 (91.7)	49 (87.5)	0.589
Age at BCPS (months)	3.7 (3.0-4.6)	3.1 (2.8-3.7)	3.9 (3.4-4.8)	0.001
Weight at BCPS (kg)	5.0 (4.6-5.6)	4.7 (4.3-5.1)	5.2 (4.8-5.9)	0.007
Weight Z score	1.7 (2.4-0.9)	1.8 (2.6-1.3)	1.7 (2.4-0.7)	0.135
Mortality after BCPS	5 (6.3)	2 (8.3)	3 (5.4)	0.614

BCPS: Bidirectional Cavopulmonary Shunt, HMP: Home Monitoring Program

Age at BCPS (p=0.015), and Z score of weight at BCPS (p=0.010) were significantly lower in patients with HMP. Mortality after BCPS was similar between the groups (p=0.500). In patients with HMP, the patient characteristics at the time of BCPS with and without readmission are shown in Table 5B. Age at BCPS (p=0.001) and weight at BCPS (p=0.007) were lower in patients who required readmission. However, mortality after BCPS was similar between patients who needed readmission and those who did not (p=0.614). Freedom from readmission is shown in Figure 3.

Inter-stage mortality was lower in patients with HMP compared to those without. Lower birth weight, ECMO support after the Norwood procedure, and lack of HMP were risks for inter-stage mortality. The most common events during home monitoring were low percutaneous oxygen saturation below 70%, infection and stagnant weight gain. One-third of the patients required unintended readmission. Age and weight at BCPS were lower in patients who needed readmission compared to those who did not. However, survival after BCPS was similar between the readmission and non-readmission groups.

Inter-stage mortality after the Norwood procedure

Inter-stage mortality accounts for an increasing proportion of mortality after the Norwood procedure. Most of inter-stage mortality occurs in patients with shunt dependent physiology between stage I and stage II palliations. Incidence of inter-stage mortality has been reported to be up to 12% in a multicenter trial [4]. Previous studies have identified several pre- and postoperative variables as risk factors for inter-stage mortality [13-16].

Home monitoring program

In 2013, our institution introduced an inter-stage HMP, which enabled more thorough patient monitoring and more frequent check-ups. The unintended benefits were earlier identification of inadequate growth and the elimination of growth failure, which is commonly reported in infants with shunt-dependent heart disease[11]. During the inter-stage period, 30% of patients were readmitted for observation with no cases of cardiac shock. Inter-stage mortality was significantly reduced from 12.4% to 2.2% after the introduction of the HMP. Two mortalities under HMP occurred in its early era (one patient in 2013 and another in 2014). Since 2015, we have not experienced any inter-stage mortality in patients who were supported by HMP. Compared to previous single- and multicenter reports, this represents a significant decrease in both overall mortality and inter-stage morbidity[9, 17-19].

After the introduction of HMP, a significantly higher number of patients were unable to be discharged prior to BCPS (12/57 vs. 8/105, P = 0.022). This was a direct result of the implementation of HMP. At the time of BCPS, the children who had been part of the HMP were significantly younger and significantly lighter than those who had been part of the remainder. At that time, their age ranged from 67 to 299 days. After BCPS, there was no discernible effect on early survival.

HMP identifies physiologic disturbances before decompensation and provides an early warning system for prompt intervention. This resulted in a significant reduction in inter-stage mortality in our population. 31% (n=14) of the patients needed inter-stage treatment due to HMP concerns and of these, 8 patients required early surgical procedures.

In line with previous publications, we matched our study participants to a historical control group. Therefore, additional confounding factors, such as developments in care over the past 19 years, may account for the reported results[9,10,20]. However, we believe that surgical modifications and the improvements of care protocols are more likely to influence the early postoperative period. The main factors affecting the inter-stage period, including imbalanced systemic and pulmonary circulation, congestive heart failure, the risk of shunt stenosis, and recurrent aortic arch stenosis, are comparable between the study groups[20].

Refining of the HMP and Future prospective

Hansen et al. suggested that the thorough pre-discharge training of parents is crucial to improve their understanding of potential problems their child may experience at home and to emphasize the importance of continuous use of the monitor in situations where they are not interacting directly with the child[9]. The HMP started with desired thresholds for SpO2 and weight change. The program was expanded to include circulatory insufficiency and failure to thrive based on initial findings, patient outcomes and parental feedback. Several programming enhancements were implemented concurrently to increase the effectiveness of this home monitoring technology. Prior to discharge, dietary targets, standard equipment, systematic data collection, educational materials, and room-in parental care were set. Imaging and laboratory data are only collected during inter-stage clinic visits if clinically necessary. The time required for pre-S2P echocardiography and cardiac catheterization varies from patient to patient. We believe that the effectiveness of the HMP has been improved by conducting consultations over the phone. The parents took advantage of additional telephone counselling, and the consistency of therapy gave the families additional confidence.

These findings do not indicate whether improved survival is due to more precise measurement of physiologic variables, improved care coordination, or both. The HMP is a complex care paradigm that improves communication between families and healthcare providers. These newborns are cared for at home by a multidisciplinary team of clinicians working closely together. In our experience, surveillance calls have lowered the threshold for contact between parents and HMP NPs. Furthermore, coordination between community cardiologists and the surgical site was improved, as was the transition from inpatient to outpatient care. If a local cardiologist or pediatrician is unavailable, the HMP provides an additional resource for the family or emergency medical personnel. The Norwood procedure with HMP is a model with far-reaching implications for the out-of-hospital care of children with chronic conditions, enabling multidisciplinary care coordination across pediatric disciplines.

Study limitations

All studies are based on observational, non-randomized data from a single center, limiting the study's ability to be generalized. We compared the study group to a historical control group, so any confounding variables, such as advances in supportive care over 19 years, could potentially explain the observed result. In addition, some of the recent patients in the control group came from abroad, some of them from regions, where medical care is not as developed as in Germany. Thirdly, some patients were in a too bad condition to be discharged until BCPS and could not be transferred to HMP. We had insufficient information regarding critical events in the control group throughout the inter-stage period, and only parents or local physicians reported the cause of death. None of the infants were subjected to post-mortem examination.

The home monitoring program, which allowed for timely intervention, primarily early stage 2 palliation, reduced inter-stage mortality significantly. A greater number of patients remained hospitalized until the bidirectional cavopulmonary shunt placement as a result of adherence to the surveillance criteria prior to discharge. In the surveillance group, earlier BCPS had no negative effect on early survival after bidirectional cavopulmonary shunt.

BCPS

bidirectional cavopulmonary shunt

CPB

cardiopulmonary bypass

ECMO

extra-corporeal membrane oxygenation

HLHS

hypoplastic left heart syndrome

HMP

home monitoring program

ICU

intensive care unit

IQR

interquartile ranges

MBTS

modified Blalock-Taussig shunt

RVPAC

right ventricle to pulmonary artery conduit

SpO2

percutaneous oxygen saturation

Author statement

The authors declare no potential conflicts of interest with respect to the research, authorship, or publication of this article.

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No competing interests reported.

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Supplementary Figure S1 Freedom from readmission after hospital discharge in patients with MBTS and with RVPAC.

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Impact of home monitoring program on inter-stage mortality after the Norwood procedure

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Abstract

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