Influence of surgical arch reconstruction methods on single ventricle workload in the Norwood procedure Keiichi Itatani, MD, Kagami Miyaji, MD, PhD,

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Influence of surgical arch reconstruction methods on single ventricle workload in the Norwood procedure Keiichi Itatani, MD, Kagami Miyaji, MD, PhD, Yi Qian, PhD, Jin Long Liu, ME, Tomoyuki Miyakoshi, ME, Arata Murakami, MD, PhD, Minoru Ono, MD, PhD, Mitsuo Umezu, PhD The Journal of Thoracic and Cardiovascular Surgery Volume 144, Issue 1, Pages 130-138 (July 2012) DOI: 10.1016/j.jtcvs.2011.08.013 Copyright © 2012 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Surgical procedure and postoperative 3-dimensional geometry of each patient. A–D, Patients with AA. E–H, Patients with AS. A, Patient 1 underwent arch reconstruction with a homograft patch after a longitudinal incision was made in the lesser curvature of the aortic arch. B, Patient 2 underwent arch reconstruction with a homograft patch after the isthmus, and the periductal tissue was completely excised. C, Patient 3 underwent arch reconstruction without patch material. The main pulmonary artery was anastomosed to the ascending aorta, aortic arch, and descending aorta after the isthmus and periductal tissue were completely excised. D, Patient 4 underwent arch reconstruction without patch material. The ascending aorta was transected and anastomosed in a side-to-side fashion to the main pulmonary artery truncating the main pulmonary artery, and then was anastomosed to the distal aortic arch in an end-to-side fashion. E, Patient 5 underwent arch repair and DKS anastomosis separately. F, Patients 6 and 7 underwent the same procedure. The main pulmonary artery, descending aorta, and aortic arch were reconstructed together in a single anastomosis after a sufficient incision was made to the ascending aorta. G, Patients 8 and 9 underwent a modified procedure as in E. Before the arch reconstruction, a longitudinal incision was made in the anterior wall of the descending aorta. AA, Aortic atresia; BSA, body surface area; AS, aortic stenosis. The Journal of Thoracic and Cardiovascular Surgery 2012 144, 130-138DOI: (10.1016/j.jtcvs.2011.08.013) Copyright © 2012 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Streamlines, wall shear stress (WSS), and total pressure (TP) distribution of patients with AA. The Journal of Thoracic and Cardiovascular Surgery 2012 144, 130-138DOI: (10.1016/j.jtcvs.2011.08.013) Copyright © 2012 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Streamlines, wall shear stress (WSS), and total pressure (TP) distribution of patients with AS. The Journal of Thoracic and Cardiovascular Surgery 2012 144, 130-138DOI: (10.1016/j.jtcvs.2011.08.013) Copyright © 2012 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 A, Energy loss (EL) profiles during 1 cardiac cycle of all patients. B, Mean EL values during 1 cardiac cycle of all patients. BSA, Body surface area. The Journal of Thoracic and Cardiovascular Surgery 2012 144, 130-138DOI: (10.1016/j.jtcvs.2011.08.013) Copyright © 2012 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 Provisory pressure-volume loop of a patient with hypoplastic left heart syndrome. A, Flow amount of pulmonary valve and atrioventricular valve assuming 4.3 L/min/m2. B, Ventricular pressure of the systemic right ventricle. C, Hypothetic pressure-volume loop. PA, Pulmonary artery. The Journal of Thoracic and Cardiovascular Surgery 2012 144, 130-138DOI: (10.1016/j.jtcvs.2011.08.013) Copyright © 2012 The American Association for Thoracic Surgery Terms and Conditions