1. HOW I DO IT ? MODIFIED NORWOOD’S OPERATION
VICHAI BENJACHOLAMAS, MD.
CHULALONGKORN HOSPITAL

2. HYPOPLASTIC LEFT HEART SYNDROME
Mitral valve atresia or stenosis
Small left ventricle
Aortic valve atresia or stenosis
Small ascending aorta
Various degree of aortic arch obstruction

3. HYPOPLASTIC LEFT HEART SYNDROME

4. HYPOPLASTIC LEFT HEART SYNDROME
Perop. Management
PGE-1  open PDA
Avoid oxygen
Correct acidosis
Inotrope
Diuretic
Intubation if neccessary

5. HYPOPLASTIC LEFT HEART SYNDROME
Hybrid procedure VS Modified Norwood’s operation

6. HYPOPLASTIC LEFT HEART SYNDROME
Hybrid procedure
PDA stenting
Bilateral PA banding
+/- balloon atrial septostomy

7. HYPOPLASTIC LEFT HEART SYNDROME
Modified Norwood’s operation
Aortic and arch reconstruction with/without homograft
Atrial septectomy
Shunt to pulmonary artery
BT shunt or Sano shunt

8. HYPOPLASTIC LEFT HEART SYNDROME
Timing for Norwood’s operation
AGE < = 10 days

9. MATERIALS AND METHODS August 1996 - November 2008
Modified Norwood’s Operation
was performed in 26 neonates

10. AGE 3 - 75 days ( median 11 days )
MATERIALS AND METHODS
AGE
days
( median 11 days )

11. WEIGHT 2,000 - 4,200 grams ( median 2,850 grams )
MATERIALS AND METHODS
WEIGHT
2, ,200 grams
( median 2,850 grams )

12. ASCENDING AORTA DIAMETER 2 - 7 mm. ( median 2.5 mm. )
MATERIALS AND METHODS
ASCENDING AORTA DIAMETER
2 - 7 mm.
( median 2.5 mm. )

13. HOW I DO IT ?

14. SURGICAL TECHNIQUE Operate under cardiopulmonary bypass
with profound hypothermia
Arterial cannulation
- at MPA for first 10 patients
- at Goretex graft to right bracheo-
cephalic artery for last 16 patients
Venous cannulation with single venous at
Rt. Atrial appendage

16. SURGICAL TECHNIQUE Resected PDA tissue and aortic ischmus
Arch reconstruction with MPA or homograft
Atrial septectomy
Rt. Modified Blalock-Taussig shunt

20. SURGICAL TECHNIQUE Homograft = 22 patients aortic = 3/22 patients
Arch reconstruction with
native MPA = patients
Homograft = 22 patients
aortic = 3/22 patients
pulmonic = 19/22 patients

22. SURGICAL TECHNIQUE BT Shunt size selection
3.5 mm. for Body weight <= 3.5 kg.
4.0 mm. for Body weight > 3.5 kg.

23. SURGICAL TECHNIQUE Median CPB time
= min. ( min.) Median DHCA time
= min. (51-97 min.)
Median CPB+ DHCA time
= min. ( min.)

24. SURGICAL TECHNIQUE
BT shunt VS
Sano shunt

25. SURGICAL TECHNIQUE
Advantages/disadvantages of the modified Blalock-Taussig shunt
Advantages
Disadvantages
No ventriculotomy
Increased diastolic runoff
Decreased coronary perfusion
Decreased right ventricle function
Decreased end organ perfusion
Limits right ventricle overload
Shunt stenosis/thrombosis
Good pulmonary artery growth

26. SURGICAL TECHNIQUE Advantages/disadvantages of the Sano shunt
Improved coronary perfusion
Higher diastolic pressure
Narrowed pulse pressure
Right ventriculotomy
Arrhythmias
Right ventricle dysfunction
Right ventricle aneurysm
Tricuspid valve dysfunction
Lower pulmonary to systemic ratio
Early or progressive hypoxemia
Pulsatile pulmonary blood flow
Increased volume load on right ventricle
Improved end-organ perfusion
Inadequate pulmonary artery growth
Shunt stenosis/thrombosis

27. Sano shunt benefit in AA, MA
SURGICAL TECHNIQUE
Sano shunt benefit in AA, MA

28. POSTOPERATIVE CARE RULE OF FOURTY (40) - Fi O2 ~ 0.40
- Pa CO 2 ~ mmHg.
- Pa O2 ~ mmHg.
- Hct. ~ 40 %

29. 78 - 85 % ( average 82 % ) POSTOPERATIVE CARE Oxygen saturation
after extubation
% ( average 82 % )

30. Survival rate = 76.9 % (20/26) RESULTS
Hospital mortality was % (6/26 )
(within 30 days)
DOT 3/6
Survival rate = 76.9 % (20/26)

31. RESULTS Mortality rate by arch reconstruction technique
Autologous tissue
mortality rate = 50 % (2/4)
survival rate = 50 % (2/4)
Homograft patch
mortality rate = 18.2 % (4/22)
survival rate = 81.8 % (18/22)

32. LATE RESULTS 26 patients 20 survivors 3 loss F/U 5 BDG
1 wait for FONTAN
4 FONTAN
2 waiting for BDG
5 not suitable for BDG
5 BTS
1 FONTAN
2 F/U
2 LD
5 LD
6 HD

33. DISCUSSION PRE-OPERATION - Need experienced cardiologist to take
care the patient before operation
- Not to put ET tube in the patient
- Stabilize cardiovascular, no acidosis

34. DISCUSSION INTRA-OPERATION - Arch reconstruction with homograft seem
to be better ( smooth postoperative care,
early extubation and no late coarctation,
especially pulmonary homograft )
- Select proper shunt size to maintain
O2 saturation ~ %

35. DISCUSSION POST-OPERATION - Early catheterization at either
5 or 6 mo. old or progress cyanosis
- Change to BCP shunt before out-growth
of the BT shunt

36. SUMMARY
The treatment of hypoplastic left heart syndrome need a lot effort. Despite good equipment, it needs very good team include neonatal cardiologist, neonatal cardiac anesthetist, neonatal cardiac surgeon, well- trained scrub nurse, keen perfusionist, and keen ICU nurse.