Aortic arch geometry after the Norwood procedure: The value of arch angle augmentation Tomomi Hasegawa, MD, PhD, Yoshihiro Oshima, MD, PhD, Ayako Maruo,

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Aortic arch geometry after the Norwood procedure: The value of arch angle augmentation Tomomi Hasegawa, MD, PhD, Yoshihiro Oshima, MD, PhD, Ayako Maruo, MD, PhD, Hironori Matsuhisa, MD, PhD, Akiko Tanaka, MD, PhD, Rei Noda, MD, Shunsuke Matsushima, MD The Journal of Thoracic and Cardiovascular Surgery Volume 150, Issue 2, Pages 358-366 (August 2015) DOI: 10.1016/j.jtcvs.2015.05.012 Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Diagram depicting the Norwood procedure. A, Augmentation of the aortic arch with GA-AP. The GA-AP is interposed between the PA and the dAo. B, Aortic arch reconstruction with right-ventricle-to-pulmonary-artery (RV-PA) shunt. Additional patch augmentation (*) for the anterior wall of the neoaorta is performed, if necessary. dAo, Descending aorta; GA-AP, glutaraldehyde-treated autologous pericardium; PA, pulmonary trunk; RV-PA, right-ventricle-to-pulmonary-artery. The Journal of Thoracic and Cardiovascular Surgery 2015 150, 358-366DOI: (10.1016/j.jtcvs.2015.05.012) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Measurement of the aortic arch geometry. A, Left lateral oblique computed tomography projection. a = arch angle (angulation between the 2 tangent lines from the highest point of the aortic arch to the centerline of the aortic arch); b = arch height (distance between the inferior margin of the aortic arch and the superior margin of the left main bronchus); X = minimal diameter of the aortic arch at the anastomotic site in the Norwood group or at the isthmus in the control group; Y = diameter of the dAo at the level of the diaphragm. The ratio of X to Y is calculated as “arch/dAo diameter ratio.” B, Axial computed tomography projection. aAo, Ascending aorta; LBr, left main bronchus; dAo, descending aorta. The Journal of Thoracic and Cardiovascular Surgery 2015 150, 358-366DOI: (10.1016/j.jtcvs.2015.05.012) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Flow diagram that demonstrates (A) the groups and (B) the postoperative events. The solid line shows the flow diagram for patients who did not undergo bPAB. The broken line shows the flow diagram for patients who underwent bPAB. HLHS, Hypoplastic left heart syndrome and its variants; IAA/CoA, interrupted aortic arch and coarctation complex with left ventricular outflow tract obstruction; bPAB, bilateral pulmonary artery banding; AAA, arch angle augmentation group (red); NA, no arch angle augmentation group (blue); BDG, bidirectional Glenn; SV, single-ventricle physiology; BV, biventricular physiology; Br/PA, reintervention and reoperation for bronchomalacia or branch pulmonary artery stenosis; reCoA, reintervention and reoperation for recoarctation. The Journal of Thoracic and Cardiovascular Surgery 2015 150, 358-366DOI: (10.1016/j.jtcvs.2015.05.012) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Freedom from reintervention/reoperation for (A) bronchomalacia and branch PA stenosis, and (B) recoarctation. AAA, Arch angle augmentation group; NA, no arch angle augmentation group. The dotted line represent the 95% confidence intervals. The Journal of Thoracic and Cardiovascular Surgery 2015 150, 358-366DOI: (10.1016/j.jtcvs.2015.05.012) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 Typical 3-dimensional multidetector-row computed tomographic angiography image in each group: (A) control patient; (B) Norwood patient, arch angle augmentation; and (C) Norwood patient, no arch angle augmentation. The Journal of Thoracic and Cardiovascular Surgery 2015 150, 358-366DOI: (10.1016/j.jtcvs.2015.05.012) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Three-dimensional MDCTA image in a patient who underwent Norwood procedure with arch angle augmentation The Journal of Thoracic and Cardiovascular Surgery 2015 150, 358-366DOI: (10.1016/j.jtcvs.2015.05.012) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions