Recoarctation of the aorta after the Norwood procedure may be treated during the second stage of the surgical palliation

HLHS: Complex Anatomic Surgical Considerations During Treatment Pathway

The Norwood operation as first-stage palliation for hypoplastic left heart syndrome has been standardized in most centers. However, in the presence of anomalies of aortic arch anatomy or position, or other anatomical variants, important modifications of the procedure may become necessary. This report summarizes surgical techniques to address these challenges.

[Early and long-term results after the Norwood procedure]

OBJECTIVE

To assess the early and long-term results after the Norwood procedure and to identify predictors of aortic recoarctation and arterial hypertension.

MATERIAL AND METHODS

We have operated on 2789 infants in the department of congenital heart diseases of the Meshalkin National Medical Research Center between January 2015 and December 2018. The current single-center prospective cohort study included 39 (1.4%) patients with hypoplastic left heart syndrome who underwent the Norwood procedure.

RESULTS

In-hospital mortality was 15.3% (n=6). An inter-stage mortality was 10.2% (n=4). Recoarctation of the aorta and Sano shunt stenosis in inter-stage period occurred in 8 (24.2%) and 4 patients (12.1%), respectively. Body mass <3 kg was the only risk factor of recoarctation (OR 7.08, 95% CI 1.17; 42.79, p=0.033). We found no risk factors of Sano shunt stenosis. There were no signs of recoarctation and Sano shunt dysfunction in the early postoperative period. Arterial hypertension developed in 14 (48.3%) patients. We found the correlation between systolic blood pressure and ventricular ejection fraction (β coefficient -0.88, 95% CI -1.33; -0.44, p=0.001). The only risk factor of arterial hypertension was increased stiffness of the aorta.

CONCLUSION

The early and inter-stage mortality are still the issues after the Norwood procedure. Postoperative reduced ejection fraction of single ventricle is one of the most common complications that could be related with residual arterial hypertension.

Aortic arch reconstruction in the Norwood procedure using a curved polytetrafluorethylene patch

OBJECTIVES

The aortic arch enlargement in the Norwood procedure is classically carried out using a curved homograft patch on the inner curvature of the neoaortic arch. The study investigates the outcome of a newly used artificial patch from a vascular prosthesis as an alternative to a homograft patch.

METHODS

Since April 2007, we used curved polytetrafluorethylene (PTFE) patches cut out of a prosthesis as an alternative to homograft patches for the aortic arch reconstruction. The decision for either patch material was made due to anatomic reasons, preferring PTFE patches in larger aortas. In this study, 224 Norwood patients, operated between April 2007 and April 2018, were analysed. A total of 104 patients received a PTFE patch (group PTFE), and 120 patients got a pulmonary homograft patch (group homograft). A single-centre retrospective analysis was carried out concerning postoperative course and long-term follow-up regarding aortic arch interventions and reoperations and comparing the 2 material groups.

RESULTS

There were no material associated operative or postoperative complications. In-hospital mortality was 13% in group PTFE. Six children died late during follow-up (6%). One aortic isthmus dilatation (1%) was carried out 12 months after the Norwood procedure in this group, no arch reoperation was necessary during the complete follow-up.

CONCLUSIONS

The curved PTFE patch showed good qualities in operative technical demands and excellent long-term results. In selected cases of hypoplastic left heart syndrome, it can be well used as alternative to the pulmonary homograft.