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Ann Thorac Surg 2003;76:1089
© 2003 The Society of Thoracic Surgeons

Invited commentary

Pediatric Cardiovascular Surgery, Duke University Medical Center, 5413 Hospital North, Box 3474, Durham, NC 27710, USA

e-mail: jagge003{at}mc.duke.edu

Fifteen years ago, low mortality with the arterial switch procedure was the measuring stick by which pediatric cardiac surgeons were measured. Because of technical modifications, increasing surgeon experience, and improvement in pediatric cardiac critical care, good outcomes are the rule rather than the exception.

In the last several years, pediatric cardiac surgical programs are increasingly being measured by results in the treatment of hypoplastic left heart syndrome (HLHS) and the Norwood procedure. While many surgeons are capable and skilled in the operation, there exists a wide discrepancy in the surgical results for these defects. Because of the complex nature of the pre- and postoperative care of these patients and the palliative nature of the repair, good results with the Norwood procedure are not only a measure of the skill of the surgeon but of the entire pediatric cardiovascular team. The paper by Mahle and associates is a report describing this group’s experience with a modifications of the Norwood procedure that has now been referred to as the Sano procedure. It does appear that the technical modification of the Norwood procedure with placement of the right ventricle to pulmonary artery conduit instead of the conventional systemic arterial to pulmonary arterial shunt may have a beneficial effect not only on the initial operative survival, but also on interim survival between first and second stage palliation. This interim mortality can be quite significant and disheartening. Just as the initial description of the Norwood procedure spawned numerous technical modifications until a fairly standard practice emerged, the Sano procedure will also be modified.

It seems that there may be many potential advantages to the placement of a right ventricular to pulmonary artery shunt. Coronary perfusion may be more stable and shunt thrombosis may be less likely in the perioperative period. In our limited experience, these babies seem better able to tolerate temporary low cardiac output and hypotension than if they had had a conventional Norwood procedure. This also seems to translate into less complex postoperative care in the ICU. There is also some suggestion that this may result in improved interim survival, although that remains to be clearly shown.

Many questions remain regarding optimal shunt size and shunt material, growth and distortion of the pulmonary arteries, effects of the small ventriculotomy on right ventricular function, potential risk of arrhythmia, and ease of the second stage palliation. In this report and others, the authors used a 5 mm conduit. It also is not clear whether this technique will be of value in all forms of HLHS that require staged palliation or just in those with aortic atresia, in which coronary perfusion can be most affected. In our limited series, we have employed a 7 mm–5 mm tapered PTFE graft. This allows a slightly larger proximal anastomosis and a smaller, flow restrictive 5-mm distal anastomosis. This type of shunt in theory may better control pulmonary blood flow and also limit the potential for shunt thrombosis. With this modification of the Sano procedure, the pulmonary and systemic circulation have been well balanced. These and other, yet to be described, techniques will continue to improve the overall outcome for these complex congenital heart defects.

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): James Jaggers Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Jaggers, J. Search for Related Content PubMed Articles by Jaggers, J. Related Collections Congenital - cyanotic