Ann Thorac Surg 2005;80:735-736
© 2005 The Society of Thoracic Surgeons
Case report
Simultaneous Second-Stage Norwood Operation and Tracheoplasty
Pablo R. García, MD
a
,
*
,
Patricio Varela, MD
b
,
Luis León, MD
a
,
Luis Sánchez, MD
a
,
Guillermo Zamora, MD
a
,
Oscar Gómez, MD
a
,
b
,
Stephan Haecker, MD
a
a Department of Cardiovascular Surgery, Luis Calvo Mackenna Children’s Hospital, University of Chile, Santiago, Chile
b Department of Surgery, Luis Calvo Mackenna Children’s Hospital, University of Chile, Santiago, Chile
Accepted for publication February 3, 2004.
* Address reprint requests to Dr García, Luis Calvo Mackenna Children’s Hospital, Antonio Varas 170 Providencia, Santiago, 21, Chile (Email: drgarcia30{at}hotmail.com).
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Abstract
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Tracheal stenosis is a rare complication that follows operations for congenital heart disease in the newborn period. We report the case of an infant with hypoplastic left heart syndrome who developed symptomatic tracheal stenosis 5 months after a first-stage Norwood operation. The combined surgical procedure of a bidirectional Glenn anastomosis and a tracheoplasty under cardiopulmonary bypass was undertaken.
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Introduction
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Following Norwood’s description in 1980 of his surgical technique for palliation of children born with the hypoplastic left heart syndrome (HLHS) [1], a number of variations in surgical strategies have been introduced to improve the clinical results and avoid the complications. Tracheal stenosis is a rare complication. Endotracheal tubes can cause ischemia and necrosis of the tracheal mucosa, even with short periods of intubation. If the erosion of the mucosa is deep enough, all layers of the trachea can be destroyed so that cicatricial repair creates a tight circumferential stenosis. In our experience, tracheal injuries are best treated by resection and reconstruction.
Our patient was the first full-term baby delivered to a twin pregnancy. He weighed 3.072 kg and had a normal Apgar score. A prenatal echocardiography disclosed HLHS, which was confirmed postnatally: parachute mitral valve (5.6 mm annulus), bicuspid aortic valve (5.5 mm ring), both with antegrade flow and mild systolic dysfunction of the right ventricle. No other cerebral and abdominal malformations were present.
The first-stage Norwood procedure was performed when he was 7 days old. Arch repair was achieved by using an aortic homograft. Arterial perfusion was accomplished with two arterial cannulas, one in the pulmonary artery and the second one in the modified Blalock-Taussig shunt (3.5 mm) [2]. Total bypass time was 150 minutes, aortic cross-clamp was 41 minutes, and circulatory arrest was 31 minutes.
The patient had an uneventful postoperative period. The sternum was left open but was closed 24 hours later, mechanical ventilation was maintained for 4 days, and the infant was discharged to his home in good clinical condition on day 15.
One month after the initial surgery, the infant presented with mild symptoms of high airway obstruction. At 4 months of age, the respiratory symptoms worsened. A rigid laryngotracheobronchoscopy was performed that confirmed tracheal stenosis at the level of the 14th tracheal ring, possibly secondary to endotracheal intubation trauma. The tracheal lumen was obstructed by 85% (Fig 1A).
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Fig 1. Before and after tracheal repair. (A) Preoperative rigid laryngotracheobronchoscopy view shows concentric stenosis in the distal trachea with more than 85% obstruction. (B) Postoperative rigid laryngotracheobronchoscopy view shows that the tracheal lumen is wide without granuloma.
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An echocardiography study at that time revealed good single-ventricle function, with an ejection fraction of 72%. Cardiac catheterization and angiography showed satisfactory pulmonary arteries and a normal pulmonary vascular resistance.
At 5 months of age, a bidirectional Glenn anastomosis was performed under cardiopulmonary bypass [3]. The trachea was freed from the posterior aspect of the neoaorta by extensive dissection. The stenotic area was identified, three tracheal rings were resected, and an end-to-end anastomosis was done with separate nonabsorbable 6-0 Prolene (Ethicon, Somerville, NJ) stitches. The suture line was placed 4 mm above the carina [4, 5]. Total bypass time was 208 minutes, and mild hypothermia (32°C) was used.
Management in the intensive care unit included 3 days on mechanical ventilation with a total hospital stay of 18 days. Tracheoscopy carried out at day 12 revealed a tracheal lumen of more than 5 mm without evidence of granuloma or stenosis (Fig 1B). The patient went home in good clinical condition with an arterial saturation of 80%.
At 18 months of age, a laparoscopic gastroesophageal fundoplication with the Nissen technique was performed for gastroesophageal reflux. At 28 months of follow-up, this patient has been free of respiratory symptoms and currently is waiting for the third-stage cardiac repair.
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Comment
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In this particular patient it was a good strategy to perform a second-stage Norwood operation along with the tracheal repair. Cardiopulmonary bypass allows unimpaired surgical exposure without hypoxemia for tracheal repair. Pathologic conditions benefit from early extubation, so the postoperative period is not managed differently.
The causes of postintubation stenosis have been well established. Prevention is possible by careful airway management during intubation, but this complication will still occur in some cases.
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References
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- Norwood WI, Kirklin JK, Sanders SP. Hypoplastic left heart syndromeExperience with palliative surgery. Am J Cardiol 1980;45:87.[Medline]
- Norwood WI, Lang P, Castaneda AR, Campbell DN. Experience for hypoplastic left heart syndrome J Thorac Cardiovasc Surg 1981;82:511.[Abstract]
- Karl TR. The bidirectional cavopulmonary shunt for hypoplastic left heart syndrome Sem Thorac Cardiovasc Surg 2001:58-70.
- Grillo HC, Donahue DM, Mathisen DJ, Wain JC, Wright CD. Postintubation tracheal stenosistreatment and results. J Thorac Cardiovasc Surg 1995;109:486-493.[Abstract/Free Full Text]
- Jaquiss RD, Lusk RP, Spray TL, Huddleston CB. Repair of long-segment tracheal stenosis in infancy J Thorac Cardiovasc Surg 1995;110:1504-1512.[Abstract/Free Full Text]
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Abstract
Introduction
