The Modified Norwood Procedure at Necker Hospital: Stage I and II for Hypoplastic Left Heart Syndrome

Abstract

We describe a modified Stage I neonatal surgical palliation for hypoplastic left heart syndrome inspired by both the Norwood and hybrid procedures. This new technique consists in: (1) replacement of the patent ductus arteriosus and aortic arch plasty with a pulmonary homograft, (2) banding of both the right and left pulmonary arteries (PA), (3) atrial septectomy, and (4) reimplantation of the Aorta (when needed). This surgery is performed under cardio-pulmonary bypass without aortic cross clamping, except when the ascending Aorta is atretic and needs to be reimplanted. Stage II consists in the division of the pulmonary bifurcation, PA branch plasty (with debanding), bidirectional cavopulmonary shunt and Damus-Kaye-Stansel anastomosis. This new surgical procedure allowed us to obtain hemodynamically stable postoperative patients and decrease by twice our mortality rate after Stage I palliation in hypoplastic left heart syndrome but with frequent left PA stenosis or hypoplasia. We describe a modified Stage I neonatal surgical palliation for hypoplastic left heart syndrome inspired by both the Norwood and hybrid procedures. This new technique consists in: (1) replacement of the patent ductus arteriosus and aortic arch plasty with a pulmonary homograft, (2) banding of both the right and left pulmonary arteries (PA), (3) atrial septectomy, and (4) reimplantation of the Aorta (when needed). This surgery is performed under cardio-pulmonary bypass without aortic cross clamping, except when the ascending Aorta is atretic and needs to be reimplanted. Stage II consists in the division of the pulmonary bifurcation, PA branch plasty (with debanding), bidirectional cavopulmonary shunt and Damus-Kaye-Stansel anastomosis. This new surgical procedure allowed us to obtain hemodynamically stable postoperative patients and decrease by twice our mortality rate after Stage I palliation in hypoplastic left heart syndrome but with frequent left PA stenosis or hypoplasia. Commentary: Norwoodized Hybrid from NeckerOperative Techniques in Thoracic and Cardiovascular SurgeryVol. 27Issue 3PreviewThe mortality associated with the Hypoplastic Left Heart Syndrome (HLHS) remains the highest among all congenital heart defects. One-year transplant-free survival for the conventional surgical palliation, the Norwood procedure, stagnates at around 70%.1 The Hybrid palliation, offers a less invasive approach with bilateral pulmonary artery banding with/out subsequent stenting of the PDA, omitting the use of cardiopulmonary bypass (CPB) in the neonatal period. Although reserved for high-risk patients with multiple risk factors who are not deemed to undergo the Norwood procedure in most centers, the Hybrid approach yields excellent outcomes in dedicated centers for allcomers. Full-Text PDF