Glenn Anastomosis Research Articles

Omission of a Prior Glenn Anastomosis Is a Risk Factor for Prolonged Pleural Drainage after the Fenestrated Extracardiac Conduit Fontan Procedure

Factors related to prolonged pleural drainage after the Fontan operation have not been clearly defined. We investigated perioperative variables to establish factors predicting operative morbidity including prolonged chest tube drainage. Also, we pursued the fate of the fenestration during the follow-up period. We retrospectively reviewed 52 patients who had undergone a fenestrated extracardiac Fontan procedure between August 1998 and June 2008. The median age at the time of surgery was 34.8 (range: 18.5 ∼ 156) months and the median body weight 13.2 kg (range: 9.5 ∼ 33). A multivariable logistic regression model was used to compare demographic, anatomic, and physiological variables for postoperative morbidity. Operative mortality occurred in one patient (1.9%). The mean duration of respiratory support, chest tube drainage, and hospital stay was 13 hours (range: 4 to 328 hours), six days (range: 2 to 45 days), and 16 days (range: 7 to 444 days), respectively. Statistically, an operation without previous bidirectional cavopulmonary shunt (OR 30, 95% CI 3.1 to 289) was the only independent risk factor for prolonged pleural drainage. Aortic cross-clamp time was identified as a risk factor for prolonged mechanical ventilatory support. During a median follow-up at 62 months (range: 17 to 137 months), there was one late death (1.9%). Twenty-two patients (43%) underwent intervention for fenestration closure. Previous bidirectional cavopulmonary shunt and shortened aortic cross-clamp time may reduce postoperative morbidity including prolonged chest tube drainage and mechanical ventilator support after the fenestrated extracardiac conduit Fontan procedure.

Surgery of the Ebstein's Anomaly: Early and Late Outcomes

Ebstein's anomaly of the tricuspid valve is a complex malformation. Several operations have been undertaken with varying results. The severity of the morphology of the lesion and ventricular function determine the spectrum of surgical techniques that are employed with varying results. Between 1980 and 2005, 45 patients with Ebstein's anomaly underwent surgical repair. Age at operation ranged from 3 to 26 years (median 15.5, mean 18.0 years). In 41 patients (91%), tricuspid valvuloplasty was done. The other four patients had valve replacement with bio-prosthesis. Eight patients required ventricular unloading by creating bidirectional Glenn procedure in addition to a valve repair. Seven needed re-operations: one repeat valve repair, two valve replacements and three takedown of Glen shunt, and one Fontan operation. In-hospital deaths occurred in two patients (4.4%) and late mortality in four patients (9%). 95% of 39 survivors were followed for 5 months to 19.5 years (median follow-up, 5.0 years; mean follow-up, 6.9 years). The actuarial survival rate (Kaplan-Meier) was 96.5%± 2.4% at 1 year, 84.4%± 3.5% at 10 years and 83.3%± 5.6% at 19 years. At follow-up 90% were in functional class I or II with substantial improvement compared with their preoperative status. Doppler echocardiographic studies demonstrated good tricuspid valve function in most patients. Valve repair or replacement tailored to the anatomical substrate of the anomaly yielded good long-term results with substantial improvement in functional status. Bidirectional Glenn anastomosis combined with a valve repair improved ventricular function and improved both the early and late outcomes.

Levosimendan treatment of severe acute congestive heart failure refractory to dobutamine/milrinone in children

Levosimendan is a novel positive inotropic agent which, improves myocardial contractility through its calcium-sensitizing action, without causing an increase in myocardial oxygen demand. Also, by opening ATP-sensitive potassium channels, it causes vasodilatation with the reduction in both afterload and preload. Because of the long half-life, its effects last for up 7 to 9 days after 24-hour infusion. We presented three patients 2, 15 and 17 years old. All the patients had severe acute deterioration of the previously diagnosed chronic heart failure (dilatative cardiomyopathy; univentricular heart with bidirectional Glenn anastomosis and restrictive bulboventricular foramen; bacterial endocarditis on artificial aortic valve with severe stenosis and regurgitation). Signs and symptoms of severe heart failure, cardiomegaly (cardio-thoracic index 0.65) and left ventricular dilatation (end-diastolic diameter z-score 2.6; 4.1 and 4.0) were confirmed on admission. Also, myocardial contractility was poor with ejection fraction (EF - 27%, 25%, 35%), fractional shortening (FS - 13%, 11%, 15%) and stroke volume (SV - 40, 60, 72 mL/m2). The treatment with standard intravenous inotropic agents resulted in no improvement but in clinical deterioration. Thus, standard intravenous inotropic support was stopped and levosimendan treatment was introduced. All the patients received a continuous 24-h infusion 0.1 microg/kg/min of levosimendan. In a single patient an initial loading dose of 11 microg/kg over 10 min was administrated, too. Levosimendan treatment resulted in both clinical and echocardiography improvement with the improved EF (42%, 34%, 44%), FS (21%, 16%, 22%) and SV (59, 82, 93 mL/m2). Hemodynamic improvement was registered too, with the reduction in heart rate in all the treated patients from 134-138 bpm before, to less than 120 bpm after the treatment. These parameters were followed by the normalization of lactate levels. Nevertheless, left ventricular end-diastolic diameter did not change after the levosimendan treatment. Our initial experience demonstrates that administration of levosimendan in patients with severe chronic heart failure not responsive to standard intravenous inotropic treatment might result in a significant clinical and hemodynamic improvement and that, in selected patients, it might be life saving. According to our best knowledge patients presented are the first pediatric patients treated with levosimendan in our country.

Paravertebral Venous Access for Closure of a Collateral in a Pediatric Patient After Fontan Operation

We report on a 16-year-old female patient with tricuspid atresia, ventricular and atrial septal defect, hypoplastic right ventricle, and pulmonary stenosis. A modified Blalock-Taussig shunt was placed within the first month of life, followed by a modified bilateral bidirectional Glenn anastomosis at 3 years and a total cavopulmonary anastomosis (TCPC) at 5 years of age. The azygous vein was ligated at the time of the Glenn procedure. The patient presented with new cyanosis (arterial oxygen saturations were 86% at rest and 76% at exercise) and a decrease in exercise capacity 11 years after TCPC. By cardiac catheterization, a significant right-to-left shunt across a collateral vessel could be detected, originating from the vertebral venous plexus and draining via the azygous system with a single opening to the pulmonary vein ( Figure 1A and Figure 1B). Repeated attempts were made at transcatheter closure through the small and tortuous feeding vessels connected to the jugular veins but were unsuccessful. Therefore, a combined surgical and transcatheter approach (hybrid procedure) was performed: After a median sternotomy, the …

Occlusion of Sano conduit with the Amplatzer Vascular Plug: A reliable method for staged elimination of accessory pulmonary blood flow in single ventricle palliation

Staged palliative surgery is often required to regulate pulmonary and systemic blood flow in children with complex congenital heart disease. Accessory sources of pulmonary blood flow have been utilized to provide satisfactory pulmonary blood flow after Glenn anastomosis in select patients. Prolonged exposure to increased flow can lead to elevated pulmonary arterial pressures and volume loading of the ventricle, potentially limiting candidacy for Fontan completion. To review the feasibility, technique, and outcome of transcatheter closure of the Sano conduit utilizing the Amplatzer Vascular Plug (AVP). All patients who underwent device closure of the Sano conduit with an AVP were reviewed retrospectively. Patient demographics, indications, procedural details, and patient outcomes were reviewed. Hemodynamic changes before and after occlusion of the Sano conduit were compared. A P value < 0.05 was considered significant. Between 2005 and 2009, 11 male patients underwent Sano occlusion with an AVP. Average weight was 8.8 ± 2.2 kg. The Sano was occluded from both antegrade (n = 6) and retrograde (n = 5) approaches. Arterial saturation and mean pulmonary artery pressure both decreased significantly after Sano occlusion [86.9 ± 4.9% to 82.6 ± 4.9% (P < 0.001) and 14.1 ± 5 mm Hg to 12.8 ± 4 mm Hg (P < 0.05), respectively]. Conduit diameter averaged 3.6 mm (range 3.1-4.4) 13 months after Stage I palliation. The conduit was closed using a 6 mm AVP in nine patients and a 4 mm AVP in the other two. The ratio of AVP size to conduit diameter was 1.5 ± 0.27. There were no procedural complications and all patients at least 2 years of age have undergone Fontan completion. The Sano conduit can be left open in select patients who do not tolerate closure after Glenn anastomosis. It can be closed safely and effectively using the AVP. © 2010 Wiley-Liss, Inc.

Aminoterminal brain-type natriuretic peptide levels correlate with heart failure in patients with bidirectional Glenn anastomosis and with morbidity after the Fontan operation

Aminoterminal brain-type natriuretic peptide levels correlate with heart failure in patients with bidirectional Glenn anastomosis and with morbidity after the Fontan operation

Operação de Fontan: uma técnica em evolução

Recent experimental flow studies based on angiography and magnetic resonance have shown that total cavopulmonary anastomosis (TCPA) is a valid concept for surgical treatment of many congenital heart defects, but there is not agreement of the best surgical arrangement. Our purpose is to analyze the immediate results with three different techniques of TCPA. We sought to analyze retrospectively all TCPA realized from January 2005 to July 2008; there were 40 patients, all with previous Glenn anastomosis, with mean age of 6.4 +/- 3.2 years. Three different techniques were employed: Group 1 (G1) lateral tunnel, Group 2 (G2) extracardiac conduits, Group 3 (G3) intracardiac conduit directed to the left pulmonary artery. All patients had a fenestration done. G1 had 11 patients, G2 10 patients and G3 19 patients. Preoperative data were similar in the 3 groups (P>0.05). Surgical mortality was higher in Groups 1 and 2 (9.1% and 10%) compared to Group 3 (0%) but there was no statistical significance (P=0.3841). Pleural effusion was absent in Group 3 (0%), which was statistically significant in relation to the other groups (P=0.0128). The hospitalization time was also significantly lower in G3 (8 days) in relation to G1 (18 days) and G2 (13 days) (P=0.0164). Intracardiac TCPA was associated with lower postoperative morbidity and is currently our preferred technique.

Poor outcome for patients with totally anomalous pulmonary venous connection and functionally single ventricle

Totally anomalous pulmonary venous connection, when also associated with a functionally univentricular connection, is known to have a poor outcome. We retrospectively analysed results for 19 patients undergoing surgery for this combination of lesions between 1995 and February 2009.Of the patients, 12 were neonates, with 11 presenting with signs of pulmonary venous obstruction. In 3 patients, a modified Blalock-Taussig shunt had been constructed. The dominant ventricle was of right ventricular morphology in 17 of the 19 patients, and double inlet was present in all bar 1. Pulmonary atresia or stenosis was found in 14 patients, a common atrioventricular junction in 14 patients, and isomerism of the right atrial appendages in 12 patients, respectively. Comprehensive Aristotle scores ranged from 14 to 23.50. The mean was 16.55, with a standard deviation of 2.19. Pulmonary venous rerouting was combined in 6 patients with construction of a modified Blalock-Taussig, in 4 with banding of the pulmonary trunk, in another 4 with a bidirectional Glenn anastomosis, in 3 with creation of a total cavo-pulmonary connection, and in 1 each with enlargement of the right ventricular outflow tract and the Norwood procedure. Of the cohort, 8 patients died early due to pulmonary hypertension, with all patients having Aristotle scores of at least 18 points dying. Among the 11 early survivors, 5 needed mechanical ventilation for over a week, but 5 patients died later, 3 due to pulmonary hypertension and 2 due to infection. Actuarial survival stabilized at 31.6%, with standard error of 10.7%, from one year onwards. Conversion to the Fontan circulation was successful in 5 patients.Our experience confirms that totally anomalous pulmonary venous connection, when associated with the functionally univentricular arrangement, carries one of the worst outcomes in current surgical practice. Use of the Aristotle comprehensive complexity scores effectively discriminates those patients with this condition at particularly high risk.

Clinical outcome of the Fontan operation in patients with impaired ventricular function☆

Although a staged Fontan strategy allows for an excellent outcome in high-risk patients, an impaired ventricular function remains a significant factor of early/late mortality and morbidity. This study evaluated the clinical outcome of the Fontan operation in patients with impaired ventricular function. A retrospective review was performed on 217 patients who had undergone the Fontan operation between 1991 and 2007. Twenty-nine (13%) of the 217 patients had an impaired ventricular function (ejection fraction (EF) <50%). The median age at the time of the operation was 3 (range: 1-31 years) years. There were five adult patients. The ventricular morphology was right in 20 patients (including five hypoplastic left heart syndrome (HLHS)) and others (left and two-ventricle) in nine patients. Heterotaxy syndrome was present in eight patients. Previous surgical interventions included bidirectional Glenn anastomoses in 24, modified Blalock-Taussig shunts in two and pulmonary artery banding in two. The preoperative EF was 43+/-6%. Significant (moderate or severe) atrioventricular valve regurgitation was noted in four patients. The percutaneous oxygen saturation (SpO(2)) was 82+/-5%. The pulmonary artery pressure and pulmonary artery index were 11+/-3 mmHg and 296+/-102 mm(2)m(-2), respectively. All 29 patients underwent the Fontan operation without any early mortality. There were two late mortalities and two re-operations. EF was maintained at 59+/-15% at a median follow-up of 7.5 (range: 1-19) years. The percent normal systemic ventricular end-diastolic volume decreased from 174+/-95% to 124+/-39% (p<0.05). The SpO(2) increased to 92+/-2%. The mean cardiothoracic ratio in chest X-ray and B-type natriuretic peptide were 51% (range: 35-68%) and 22 pgml(-1) (range: 9-382 pgml(-1)), respectively. Three patients developed congestive heart failure, seven had arrhythmia and two developed protein-losing enteropathy. The New York Heart Association (NYHA) class functional class is I in 21 patients, II in five and III in one. Acceptable clinical outcomes were observed at an intermediate follow-up of the Fontan operation in patients with an impaired ventricular function.

Total Cavopulmonary Connection: Lateral Tunnel Anastomosis or Extracardiac Conduit? — an Analysis of 114 Consecutive Patients

To compare the postoperative outcomes of patients with the diagnostic univentricular heart undergoing lateral tunnel (LT) operation with extracardiac conduit (EC) operation. From June 1996 to July 2007, 114 consecutive patients with a single ventricle underwent total cavopulmonary connection (TCPC) in Children's Heart Center, University Hospital Giessen and Marburg GmbH, Germany. A LT was performed in 19 (16.7%) patients, and an EC in 95 (83.3%) patients. The mean age of EC group was 50.8 +/- 31.6 (ranging from 22 to 212) months, and that of LT group was 61.5 +/- 41.2 (ranging from 30 to 168) months. Early and midterm outcomes of two groups were analyzed. One died in LT group (5.3%) and three in EC group (3.2%). The overall mortality was 3.5%. There was no significant difference in mortality between EC and LT groups (P>0.05). The postoperative pulmonary arterial pressure, oxygen saturation, and effusion time of two groups had no significant difference (all P>0.05). No significant difference in the occurrences of complications (arrhythmias, enteropathy, and thrombosis) was found between two groups after operation (P>0.05). There seems no difference between LT and EC in the clinical results in the early and middle postoperative stage. Glenn anastomosis followed by an EC seems to have some advantages.

Aminoterminal brain-type natriuretic peptide levels correlate with heart failure in patients with bidirectional Glenn anastomosis and with morbidity after the Fontan operation

The aims of this study were to generate normal values of aminoterminal pro-brain natriuretic peptide in children with a bidirectional Glenn anastomosis without congestive heart failure and to test the hypothesis that plasma levels of aminoterminal pro-brain natriuretic peptide correlate with the clinical severity of congestive heart failure and morbidity after the Fontan operation. Aminoterminal pro-brain natriuretic peptide plasma levels of 78 patients after the bidirectional Glenn operation with a median age of 3.2 years and a median follow-up time of 3 years were measured by using an automated enzyme immunoassay. The severity of heart failure was quantified by using the New York University Pediatric Heart Failure Index. The 97.5th percentile of aminoterminal pro-brain natriuretic peptide level in patients without congestive heart failure was 339 pg/mL. Aminoterminal pro-brain natriuretic peptide levels strongly correlated with the New York University Pediatric Heart Failure Index score (P < .001). In patients with congestive heart failure (31/78), the aminoterminal pro-brain natriuretic peptide levels were significantly higher (median, 670 pg/mL) than in patients without congestive heart failure (median, 171 pg/mL). In 41 patients who underwent the Fontan operation, the time to removal of chest tubes and the length of hospital stay positively correlated with the preoperative value of aminoterminal pro-brain natriuretic peptide. In children with a bidirectional Glenn anastomosis without signs of heart failure, aminoterminal pro-brain natriuretic peptide levels were within the normal range and correlated with the severity of congestive heart failure. Further studies are needed to determine whether aminoterminal pro-brain natriuretic peptide levels can aide clinicians in the early detection of congestive heart failure in this patient group.

Bidirectional Glenn with Existing Transvenous Cardioverter-Defibrillator Leads

The population of patients with adult congenital heart disease is increasing. A significant number of these patients already have or will require placement of either a transvenous pacemaker or implantable cardioverter defibrillator. In addition to this, some with right ventricular dysfunction might benefit from volume unloading of the right ventricle by the construction of a superior cavopulmonary anastomosis. The usual technique for the bidirectional Glenn anastomosis precludes the presence of upper extremity transvenous hardware. We present a modified technique for the superior cavopulmonary anastomosis when pacing or cardioverter defibrillator leads are present.

Acute Adaptation to Volume Unloading of the Functional Single Ventricle in Children Undergoing Bidirectional Glenn Anastomosis

Objective. Volume unloading of the functional single ventricle after a bidirectional Glenn anastomosis (BDG) prior to 1 year of age leads to improved global ventricular function as measured by the myocardial performance index (MPI), a Doppler-derived measurement of combined systolic and diastolic ventricular function. Systolic function remains unchanged after BDG according to previous studies; however, acute changes in global and diastolic function have not been previously investigated in this cohort. Our objective was to assess the short-term effects of the BDG on global ventricular function in patients with a functional single ventricle. Design. Echocardiograms to obtain MPI, isovolumic contraction time, and isovolumic relaxation time were performed at four time periods: in the operating room, in the operating room prior to BDG, shortly after separation from cardiopulmonary bypass, less than 24 hours postoperatively, and either prior to hospital discharge or at the first clinic follow-up visit. Results. Twenty-six patients were enrolled. There was significant ventricular dysfunction noted shortly after separation from cardiopulmonary bypass, median MPI 0.63 (0.39–0.81), that persisted in the short term postoperatively median MPI 0.50 (0.40–0.63). Isovolumic contraction time did not change, however, isovolumic relaxation time was significantly prolonged following BDG. Conclusion. In the postoperative patient after BDG, systolic function is preserved; however, there is evidence of diastolic and global ventricular dysfunction, at least in the short term.

Repair for acute type A aortic dissection with a long elephant trunk technique

superior cavopulmonary anastomosis was effective and functioned well for 2 years in a patient with huge right ventricular fibroma. As for methodology of superior cavopulmonary anastomosis, bidirectional Glenn anastomosis is preferred to hemi-Fontan procedure because the superior vena cava should be disconnected from the right atrium to guard cavopulmonary anastomosis against tumor extension into the right atrium or right atrial thrombus secondary to right ventricular obstruction. Although surgical excision does not cure the primary disease in metastatic tumors of the heart, palliative resection may be justified for immediate life-threatening danger due to an intracavity space-occupying lesion. Additional bidirectional cavopulmonary anastomosis may provide assurance in long-term pulmonary blood flow in unresectable cardiac metastasis.

Crisscross Hearts in Adults: Echocardiographic Evaluation and Natural History

Crisscross heart is a rare congenital, rotational abnormality of the ventricular mass, resulting in the crossing of the inflows of the 2 ventricles and each atrium emptying into the contralaterally located ventricle. Few cases of adult patients are described in the literature. We present a case series of 7 adult patients aged 18 to 53 years with crisscross hearts, followed up for 5 to 22 years (mean 14.4 years) at the Institute of Cardiology Warsaw. Only in 2 patients was the diagnosis of crisscross heart made at infancy. In the remaining 5 patients, the diagnosis was made at the age of 7 to 26 years. All patients had complex congenital heart defects, including double outlet right ventricle in 4 patients and discordant ventriculoarterial connections in 3 patients, with numerous associated lesions. In all patients, the diagnosis of crisscross heart was made by transthoracic echocardiographic examination. Five patients underwent surgical procedures, including Rastelli operation, arterial switch, Glenn anastomosis, and central shunt, according to the individual morphology and hemodynamics. The clinical outcome depended predominantly on the underlying hemodynamic abnormalities and the results of surgical management rather than on crisscross anatomy. Successful surgery allowed acceptable functional status in adulthood.

Palliative bidirectional Glenn anastomosis for unresectable metastasis in the right ventricle from renal cell carcinoma 16 years after nephrectomy

plantation relative to the transfemoral approach. A patent left internal thoracic artery graft is probably a contraindication to a left axillary approach. The potential to compromise innominate artery flow is a relative contraindication to the right axillary approach. The trans–axillary artery approach offers an additional tool in the new armamentarium for the treatment of aortic stenosis in patients who are candidates for TAVI but who have significant respiratory dysfunction and problematic iliofemoral access precluding the other available techniques. We also believe that it offers some advantages relative to the transfemoral and transapical approaches and is worthy of evaluation in a broader patient population as an alternative access route.

Interventions Complementing Surgery as Part of Multistage Treatment for Hypoplastic Left Heart Syndrome: One Center’s Experience

Interventional procedures often are used as part of multistage treatment for hypoplastic left heart syndrome (HLHS). This study aimed to evaluate the efficacy of interventions in multistage treatment of HLHS. Between 1999 and 2007, 78 interventions were performed for 58 children with HLHS at different stages of surgical treatment. Group 1, involving 30 interventions for 22 patients with postoperative pulmonary arterial stenosis, showed reduced pulmonary artery pressure and increased vessel diameter. Group 2, involving 15 interventions after the Norwood operation for 12 patients with aortic arch obstruction, showed success for 11 patients. Group 3, involving eight balloon angioplasties of narrowed Glenn anastomosis for seven patients, showed abolition of the pressure gradient between the superior vena cava and the right pulmonary artery. Group 4, involving eight interventional closures of a fenestration for eight patients after a Fontan operation, showed increased oxygen saturation for all eight patients. Group 5, involving seven interventions for six patients in whom venovenous collaterals were closed percutaneously, showed improved oxygen saturation. For Group 6, uncommon miscellaneous interventions were used to stabilize the patients' condition before the next surgical treatment. Interventional procedures play an important role during multistage treatment of HLHS. They allow for a reduction in the number of operations or stabilization of the patients' condition before the next surgical treatment.

Hybrid Therapy for Hypoplastic Left Heart Syndrome: Reality Check

Pilla et al. [2] are to be congratulated and commended for their honesty and integrity in reporting an unfavorable outcome for the new management strategy of patients with hypoplastic left heart syndrome (HLHS) in their article in this issue of Pediatric Cardiology. What is a hybrid intervention for HLHS? And why do it? Hybrid therapy refers to a collaborative effort between a cardiac surgeon and an interventional cardiologist in managing these patients. Ideally, this is conducted in a hybrid suite. Through a median sternotomy, the surgeon bands the branch pulmonary arteries (left and right), followed by stent implantation in the ductus arteriosus by the interventional cardiologist. In the event the atrial septal communication is restrictive, a stent is placed across the patent foramen ovale either percutaneously or via a peratrial route. This procedure is completed without the need for cardiopulmonary bypass. A few months later, when the infant is larger, a comprehensive stage II (Norwood) with a bidirectional Glenn anastomosis is performed. The obvious advantage of such an approach is the avoidance of a major operation with potential circulatory arrest in the immediate neonatal period with the known risks this carries on the developing brain. In addition, some believe that by postponing a major procedure until the infant is a few months of age, the mortality rate associated with the Norwood operation is reduced. Many centers throughout the world, including experienced centers in the United States, report high surgical mortality for the Norwood operation performed in the immediate neonatal period. In a study by the Congenital Heart Surgeon Society involving 29 centers and 710 neonates from 1994 to 2000, only 54% of patients with HLHS were alive after the Fontan operation [1]. Mortality continues to be high even with modifications of the Norwood, such as the Sano operation, in which a conduit is placed between the right ventricle and the main pulmonary artery. Additional complications may occur in the future after the Sano procedure secondary to right ventriculotomy. This has led some experienced surgeons to abandon this modification. With the newer innovation of the hybrid intervention, many believed that adopting this technique would result in a decreased mortality rate for HLHS. Unfortunately, this was not the case, as shown in the study of Pilla et al., in which there was a high mortality rate for their group of patients. In examining this study, I believe there are potential factors that have contributed to this unwanted outcome, including the small sample size at each site, the different postoperative management strategies for each site, and the lack of infrastructure. Even in centers with good postoperative management and strong infrastructure, the mortality rate of this new hybrid therapy is still high. The group at Nationwide Children’s Hospital in Columbus, Ohio, and our group in Chicago had to change the approach a few times until mortality was decreased with better outcome. It is perhaps advisable for centers wanting to pursue the hybrid approach to management of HLHS to collaborate with centers with well-established track records, such as the team at Columbus, and witness first hand the hybrid procedure and postoperative care that follows. This can be followed by proctoring by experienced cardiologists and surgeons, such as those from Columbus or the group in Giessen, Germany, conducted at the institution seeking to adopt this new methodology. Z. M. Hijazi (&) Rush Center for Congenital & Structural Heart Disease, Rush University Medical Center, Jones 770, 1653 W. Congress Parkway, Chicago, IL 60612, USA e-mail: zhijazi@rush.edu

Interventional Catheterization After the Norwood Procedure

To carry out a retrospective analysis of the indications for, and the results and complications of interventional catheterization after the Norwood procedure. Between February 1993 and December 2006, 25 interventional catheterizations were performed in 14 patients who had undergone the Norwood procedure, prior to the Glenn or Fontan procedure. Nine angioplasties were carried out for recoarctation in seven of the 14 patients (2 patients developed restenosis after their first angioplasty). Detachment of the left pulmonary artery occurred either immediately or during follow-up in 3 patients who underwent the classical Norwood procedure. Overall, 10 pulmonary artery angioplasties were required in 7 patients. Three patients needed embolization: one of venous collaterals (using coils), one of the left superior vena cava (using an Amplatzer duct occluder), and one of a left Blalock-Taussig shunt (using an Amplatzer duct occluder). Two patients required a cavopulmonary (Glenn) anastomosis, and another underwent fibrinolysis for thrombosis of the superior vena cava and pulmonary artery. Other findings, which were not treated percutaneously, included: stenosis of the supra-aortic trunk (n=6), femoral artery stenosis (n=2), femoral vein thrombosis (n=5), and subclavian vein thrombosis (n=1). The following complications were recorded: arterial ischemia (n=2), cardiac arrest or bradycardia (n=4), and transient atrioventricular block (n=1). Following stage I of the Norwood procedure, the angiographic and hemodynamic assessments needed for the diagnosis and treatment of pulmonary artery or aortic arch stenosis must be carried out promptly. Although treating recoarctation by angioplasty can be effective, restenosis frequently occurs. With the Sano procedure, detachment of the left pulmonary artery, but not pulmonary artery stenosis, can be avoided. After stage II, the presence of venovenous collaterals must be ruled out, because they frequently require embolization. In these patients, interventional catheterization is associated with a higher incidence of complications than in other groups.

Total cavo-pulmonary connection without foreign material for asplenic heart associated with partial anomalous pulmonary venous connection

The presented case was a 3-year-old boy diagnosed with asplenia (SLL), double outlet right ventricle, pulmonary stenosis, atrioventricular septal defect, hypoplastic left ventricle and partial anomalous pulmonary venous connection to the superior vena cava. Partial anomalous pulmonary venous connection was repaired by translocation of pulmonary artery to avoid pulmonary venous obstruction when Glenn anastomosis was performed. Total cavo-pulmonary connection was established by re-routing the inferior vena cava to pulmonary artery using the atrial septal remnant and the left atrium free wall flap.