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Ann Thorac Surg 1996;62:76-77
© 1996 The Society of Thoracic Surgeons
DR DAVID A. FULLERTON (Denver, CO): I congratulate you, Dr Bando, on a beautiful presentation. In your characteristic style, it was very crisp and very clear. I also congratulate the group at Indiana University on a superb clinical experience. I think those of us involved in infant heart transplantation can appreciate that this is a very difficult group of patients, and your results are clearly among the best reported.
I believe this is an important clinical series for a couple of reasons, but primarily because it demonstrates that within one institution, the group of physicians involved can offer two methods of treatment and perform each quite well. For instance, at my institution, we have elected to do transplantation for all of these infants. In recent years, other groups in addition to yours have demonstrated success with the Norwood procedure, and so the pendulum is beginning to swing the other way. I think your group is taking the leadership role in demonstrating that such results can be produced in the same institution.
Along these lines, I wonder if you could elaborate a little bit on how you get these results. For patients who undergo a Norwood procedure, the tricky part is the early postoperative management. Do you leave the chest open? Do you have a particular focus on acid-base regulation for the control of pulmonary vascular resistance?
For the infants who are going to undergo heart transplantation, I think the more difficult area is the preoperative management. At my institution, we add supplemental nitrogen to the inspired oxygen to try to minimize pulmonary blood flow and have found that useful.
I emphasize the problems with pulmonary vascular resistance that you have seen with a protracted waiting period. The last several infants having transplantation by us waited for 3 to 6 months on a regimen of prostaglandins. Although the infants survived, it was a real struggle for everybody.
Again, I compliment you on a very nice presentation and a beautiful series and would appreciate your insights on these perioperative management issues.
DR BANDO: Thank you very much for your comments, Dr Fullerton. We also have a difficult time with the postoperative management of the palliation group. Regarding acid-base regulation, we are aiming at a pH of 7.4, a carbon dioxide tension of 40 mm Hg, and an oxygen tension of 40 mm Hg as our "gold standard." Although we have been having problems with both inadequate pulmonary flow and excessive pulmonary flow, we have seen more problems with the latter. Two patients with 4-mm shunts have required restriction of the shunt because of too much pulmonary flow. Those patients had 4% carbon dioxide added to the inspired gas, but this did not adequately reduce pulmonary flow. Since we changed the shunt size from 4 mm to 3.5 mm for babies weighing less than 4 kg, our postoperative management has been simplified. We are now using less carbon dioxide. I believe this change had a major impact on the improvement in our early postoperative results.
Regarding heart transplant candidates, it remains difficult to find suitable donor hearts in a short time frame, and we do not yet know how long we should wait. As our results with palliation have been improving, we electively cross over to a Norwood procedure if we do not find a donor heart before the child reaches 30 days of age.
DR CONSTANTINE MAVROUDIS (Chicago, IL): That was a very nice paper. At Children's Memorial Hospital in Chicago, we, too, are progressing from transplantation to the Norwood operation for babies with hypoplastic left heart syndrome because of the long wait for a heart.
I have a question about the neurologic status of your patients. There has been increasing awareness of microcephaly, chromosomal abnormalities, and other extracardiac lesions in these patients that may obviate any kind of therapy. In fact, some of these studies show extracardiac abnormalities in as many as 30% of patients with hypoplastic left heart syndrome. How many extracardiac abnormalities did you encounter in your series of 86 patients?
DR BANDO: Thank you, Dr Mavroudis. As I mentioned, 36 of the86 patients did not have operation. Patients who had known chromosomal abnormalities or major noncardiac abnormalities and infants whose condition could not be stabilized with appropriate medical therapy did not undergo operation. Ultrasonography of the head and abdomen has been used to exclude associated noncardiac abnormalities. On the basis of this information, the infant's status, and the family situation, both pediatric cardiologists and cardiac surgeons decided not to pursue surgical intervention for these 36 patients. I believe selection of the appropriate patient is very important.
Related Article
Ann. Thorac. Surg. 1996 62: 70-76.
This article has been cited by other articles:
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  E. Malec, K. Januszewska, J. Kolcz, and J. Pajak Factors influencing early outcome of Norwood procedure for hypoplastic left heart syndrome Eur J Cardiothorac Surg, August 1, 2000; 18(2): 202 - 206. [Abstract] [Full Text] [PDF]
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