Rapid Two-Stage Norwood Procedure Using an Auto-Pericardial Patch Fixed with an Arch-Shaped Mold

Abstract

While the classical 1-stage Norwood procedure is still performed, there are several types of “hybrid” procedures for the management of hypoplastic left heart syndrome. These hybrid approaches consist of bilateral pulmonary artery banding with ductal stenting or prostaglandin infusion as the first-stage palliation, followed by a second-stage Norwood procedure or comprehensive stage II procedure. Since 2012, we have adopted a rapid 2-stage Norwood procedure as a routine strategy, where bilateral pulmonary artery banding is performed within 5 days of age with balloon atrial septectomy, if needed, before the development of hemodynamic instability. The second-stage Norwood procedure is performed within 1 month of age. The arterial duct is kept open by continuing prostaglandin administration. In addition, an important improvement of our Norwood procedure is the use of an auto-pericardial patch fixed on an arch-shaped metal mold. The pericardium is wrapped around the lesser curvature of the mold and treated with 0.6% glutaraldehyde for 15 min. This makes it easier to imagine the final shape of the arch and helps to enlarge the retroaortic space significantly, which could reduce the risk of bronchus or central pulmonary artery stenosis and facilitate hemostasis. These developments in strategy and procedure could improve our surgical results. While the classical 1-stage Norwood procedure is still performed, there are several types of “hybrid” procedures for the management of hypoplastic left heart syndrome. These hybrid approaches consist of bilateral pulmonary artery banding with ductal stenting or prostaglandin infusion as the first-stage palliation, followed by a second-stage Norwood procedure or comprehensive stage II procedure. Since 2012, we have adopted a rapid 2-stage Norwood procedure as a routine strategy, where bilateral pulmonary artery banding is performed within 5 days of age with balloon atrial septectomy, if needed, before the development of hemodynamic instability. The second-stage Norwood procedure is performed within 1 month of age. The arterial duct is kept open by continuing prostaglandin administration. In addition, an important improvement of our Norwood procedure is the use of an auto-pericardial patch fixed on an arch-shaped metal mold. The pericardium is wrapped around the lesser curvature of the mold and treated with 0.6% glutaraldehyde for 15 min. This makes it easier to imagine the final shape of the arch and helps to enlarge the retroaortic space significantly, which could reduce the risk of bronchus or central pulmonary artery stenosis and facilitate hemostasis. These developments in strategy and procedure could improve our surgical results.