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Ann Thorac Surg 1999;68:559-561
© 1999 The Society of Thoracic Surgeons

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Case Reports

Norwood procedure without circulatory arrest

^a Cardiovascular Surgery, Fukuoka Children’s HospitalKyushu University, Fukuoka, Japan
^b Division of Cardiovascular Surgery, Kyushu University, Fukuoka, Japan

Address reprint requests to Dr Imoto, Cardiovascular Surgery, Fukuoka Children’s Hospital, 2-5-1 Tojinmachi, Chuo-ku, Fukuoka 810-0063, Japan

	Abstract

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In the Norwood procedure for hypoplastic left heart yndrome, the distal descending thoracic aorta was cannulated just superior to the diaphragm through median sternotomy. In combination with cerebral perfusion through the graft anastomosed to the innominate artery, which was used as a systemic-to-pulmonary shunt later, this technique enabled us to completely avoid circulatory arrest and deep hypothermia throughout the operation.

	Introduction

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Circulatory arrest with deep hypothermia is commonly used during the aortic arch reconstruction in hypoplastic left heart syndrome (HLHS). Although it is a useful technique, potential risks of complications such as neurological damage [1] and renal failure [2] cannot be ignored. We introduced a new cardiopulmonary bypass technique using arterial cannulation of the distal descending thoracic aorta through median sternotomy combined with cerebral perfusion through the innominate artery to avoid circulatory arrest. Details of this technique are described in this report.

The patient was a 15-day-old girl with a body weight of 2.550 g. She had aortic atresia and mitral stenosis with hypoplastic left ventricle. Outer diameters of the ascending and descending aortas were 3.5 mm and 6.0 mm, respectively. After median sternotomy, expanded-polytetrafluoroethylene (E-PTFE) graft, 3.5 mm in diameter, was sewn to the innominate artery. Cardiopulmonary bypass was commenced with bicaval venous cannulas and with the graft at the innominate artery as an arterial line. Then the heart was gently elevated and a small incision was made in the posterior pericardium, to the left of the inferior vena cava (Fig 1). The descending aorta was identified easily and localized dissection was carried out to expose it clearly. An angled, metal-tipped cannula (2.1 mm in outer diameter, Japan Medical Supply Co, Hiroshima, Japan) was inserted through a purse string suture of 4-0 polyester placed in the aorta. Thereafter, extracorporeal circulation (ECC) with single pump and double arterial lines was established (Fig 2A). Pump-flows were maintained at 180 mL/min/kg, and the rectal temperature was lowered to 30.4°C. After cross-clamping the distal arch, the left subclavian artery and the descending aorta, the ductus arteriosus was ligated and coarctectomy was performed. The aortic arch and the descending aorta were then anastomosed with continuous 7-0 polydioxanone suture in an end-to-end fashion. The atrial septal defect was enlarged through the right atriotomy. The pulmonary trunk was transected and the distal end was closed. After clamping all the arch vessels and the descending aorta, a longitudinal incision extending from the ascending aorta to the undersurface of the arch was made (Fig 2B), and cardiac arrest was obtained with crystalloid cardioplegia infused through the aortotomy. The neoaorta was constructed by direct anastomosis of the pulmonary trunk to the ascending aorta and the aortic arch [3]. All the clamps were then removed. Myocardial ischemic time was 32 minutes. Perfusion to the innominate artery was stopped and the whole body was perfused by the arterial cannula in the descending aorta. Modified Blalock-Taussig shunt was completed by anastomosing the distal end of the graft to the right pulmonary artery. Weaning from bypass was easy, and the cannula in the descending aorta was removed without any trouble. Extracorporeal circulation time was 172 minutes. Postoperative course was uneventful, and there was no neurological deficit. Urinary output was maintained at a very satisfactory level during and after ECC, and in fact it reached 305 mL during the first 24 hours in the intensive care unit. The maximum serum blood urea nitrogen (BUN) and creatinine levels in the postoperative course were 24 mg/dL and 0.6 mg/dL, respectively. Postoperative echocardiography showed trivial tricuspid regurgitation. Shunt murmur was well audible and the oxygen saturation in arterial blood was 84%. She has been followed up for 5 months, and is expected to undergo a bidirectional Glenn procedure within a year.

View larger version (145K): [in this window] [in a new window]   Fig 1. Intraoperative photograph of the cannula inserted into the descending aorta. Des Ao cannula = arterial cannula in the descending aorta; G = graft sewn to the innominate artery. The heart is slightly elevated.

View larger version (21K): [in this window] [in a new window]   Fig 2. (A) Extracorporeal circulation using cerebral perfusion through the graft at the innominate artery and the lower body perfusion through the arterial cannula inserted in the descending aorta. E-PTFE = expanded polytetrafluoroethylene; Innom a = innominate artery; Des Ao = descending aorta. (B) Construction of the neoaorta with direct anastomosis between the main pulmonary artery (MPA) to the ascending aorta (Asc Ao) and the aortic arch. Peripheral pulmonary arteries are omitted in this illustration.

	Comment

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Cannulation of the descending aorta through median sternotomy has been reported as an alternative technique for emergency cannulation in adults who have atherosclerotic disease in the abdominal aorta [6]. In neonates and infants, this approach seems much easier and safer than in adults, because the cannulation site is not too deep from the skin incision and there is no atheromatous change on the internal surface. Minimum dissection of the descending aorta is recommended to prevent bleeding and injury of the adjacent organs.

Our previous report on cerebral perfusion through the innominate artery showed existence of significant communication between the right and left hemispheres of the brain via the circle of Willis [4]. Nevertheless, intraoperative pressure monitoring of the left superficial temporal artery is recommended as far as possible for the sake of safety. Proximal anastomosis of modified Blalock-Taussig shunt was performed before construction of the neo-aorta to be used as an arterial line. One of the advantages of this method is that the graft does not cause excessive tension to the innominate artery in contrast to a rigid cannula. However, the proximal anastomosis might be distorted by alteration of tension or torque on the innominate artery when arch reconstruction is completed; such a condition must be carefully avoided.

In conclusion, cannulation of the distal descending thoracic aorta through median sternotomy seems an easy, safe, and effective technique for perfusion of the lower body in Norwood operation. Combination of this technique and cerebral perfusion through the innominate artery enables complete avoidance of circulatory arrest and deep hypothermia throughout the operation.

	References

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1. Bellinger D.C., Jonas R.A., Rappaport L.A., et al. Developmental and neurologic status of children after heart surgery with hypothermic circulatory arrest or low-flow cardiopulmonary bypass. N Engl J Med 1995;332:549-555.[Abstract/Free Full Text]
2. Asfour B., Bruker B., Kehl H.G., Frund S., Scheld H.H. Renal insufficiency in neonates after cardiac surgery. Clin Nephrol 1996;46:59-63.[Medline]
3. Fraser C.D., Mee R.B.B. Modified Norwood procedure for hypoplastic left heart syndrome. Ann Thorac Surg 1995;60:S546-S549.
4. Asou T., Kado H., Imoto Y., et al. Selective cerebral perfusion technique during aortic arch repair in neonates. Ann Thorac Surg 1996;61:1546-1548.[Abstract/Free Full Text]
5. Yasui H., Kado H., Yonenaga K., et al. Revised technique of cardiopulmonary bypass in one-stage repair of interrupted aortic arch complex. Ann Thorac Surg 1993;55:1166-1171.[Abstract]
6. Cooley D.A. Cannulation for temporary bypass. In: Cooley D.A., ed. Techniques in cardiac surgery, 2nd ed. Philadelphia: W. B. Saunders, 1984:83-97.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Imoto, Y. Articles by Yasui, H. Search for Related Content PubMed PubMed Citation Articles by Imoto, Y. Articles by Yasui, H.