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Ann Thorac Surg 2004;77:908-912
© 2004 The Society of Thoracic Surgeons

Original article: cardiovascular

The low resistance strategy for the perioperative management of the Norwood procedure

Toshihide Nakano, MDa, Hideaki Kado, MDa*, Yuichi Shiokawa, MDa, Koji Fukae, MDa, Yosuke Nishimura, MDa, Kazuyuki Miyamoto, MDa, Yoshihisa Tanoue, MDa, Hideki Tatewaki, MDa, Naoki Fusazaki, MDb

a Department of Cardiovascular Surgery, Fukuoka, Japan
b Department of Neonatal Cardiology, Fukuoka Children's Hospital, Fukuoka, Japan

Accepted for publication September 5, 2003.

* Address reprint requests to Dr Kado, Department of Cardiovascular Surgery, Fukuoka Children's Hospital, 2-5-1 Tojin-machi, Chuo-ku, Fukuoka 810-0063, Japan
e-mail: kado{at}pluto.dti.ne.jp

BACKGROUND: Postoperative course of the Norwood procedure is fragile because of an unstable pulmonary to systemic blood flow ratio caused by fluctuation of systemic and pulmonary vascular resistance.

METHODS: Twenty-seven patients with hypoplastic left heart syndrome who underwent the Norwood procedure from June 1998 to February 2002 were managed with the following low-resistance strategy. Intraoperative high-flow and low-resistance cardiopulmonary bypass was achieved with total avoidance of circulatory arrest and a large dose of chlorpromazine. In weaning from the bypass, pulmonary vascular resistance was maximally decreased by inspired oxygen fraction (100%), inhaled nitric oxide (20 ppm), and nitroglycerin (2 to 4 µg/kg/min). Then pulmonary blood flow was determined by adjusting the systemic to pulmonary shunt. Postoperatively, with continuous infusion of chlorpromazine and nitroglycerin as a systemic and pulmonary vasodilator, the inspired oxygen fraction and inhaled nitric oxide were tapered as the arterial oxygen saturation improved.

RESULTS: In most patients, inhaled nitrous oxide and inspired oxygen fraction were weaned within 3 days. The postoperative course was stable with minimum changes in circulatory and respiratory status for the survivors. Patients were extubated on a median of 6 postoperative days. Early mortality was 11.1% (3 of 27), and none of the patients died of hemodynamic deterioration.

CONCLUSIONS: The low resistance strategy is a simple and useful method for perioperative management of the Norwood procedure, minimizing fluctuation in both pulmonary and systemic vascular resistance and maintaining stable circulatory and respiratory status.




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