Abstract 4144912: Doing Well, But Can We Do Better? Improving Outcomes and Equity After Stage I Single Ventricle Palliation

Introduction: Infants with hypoplastic left heart syndrome undergoing single ventricle (SV) palliation may need early heart transplant. We aimed to evaluate predictors of transplant referral (TxR) and death without TxR, with focus on neighborhood opportunity and race/ethnicity, to determine if disparities in TxR contribute to increased mortality seen in certain populations. Methods: Retrospective cohort study of all infants undergoing stage 1 (S1) SV palliation enrolled in the National Pediatric Cardiology Quality Improvement Collaborative from 2016-2022 was performed. Competing risk analysis was used to evaluate predictors of TxR and death without TxR through one year. Results: A total of 3099 infants underwent S1 palliation during our study period. Black children had lower median birth weight compared to non-Hispanic white and Hispanic children (p <0.001) as did those from low compared to higher opportunity neighborhoods (p <0.001). There were no other significant pre-operative or S1 procedure differences. At one year, 79% of children were alive, 16% had died, and 5% had a TxR (Figure). In multivariable analysis, risk factors for TxR included hybrid S1 palliation [sHR 2.43 (95% CI 1.54, 3.81], moderate or greater tricuspid regurgitation (TR) [sHR 3.39 (95% CI 1.80 – 6.40)] and female sex [sHR 1.73 (95% CI 1.24 – 2.40)]. Lower birth weight, genetic syndrome, pre-operative TR, hybrid S1 palliation, and small S1 volume (<8 /yr) center were associated with death without TxR. Neither race/ethnicity nor neighborhood opportunity was associated with TxR or death without TxR when controlling for these risk factors. Among those with pre-operative moderate or greater TR, race/ethnicity was associated with TxR in multivariable analysis, with TxR less likely for Black and Other race children compared to white children (p<0.001 for both). Conclusion: One-year survival after S1 palliation without TxR approaches 80%. No clear disparities in death or TxR by race or neighborhood were seen overall, though lower rates of TxR for Black and Other race children with high-risk cardiac features were present. Standardized guidelines for timely TxR may help further reduce death and mitigate potential disparities in this SV population.