Ann Thorac Surg 2005;80:e14-e16
© 2005 The Society of Thoracic Surgeons
How to do it
Modified Children's II Operation on the Beating Heart Allows Growth Potential
Boulos Asfour, MD, PhD
*
,
Christoph Fink, MD,
Nicodème Sinzobahamvya, MD,
Jutta Wetter, MD,
Andreas E. Urban, MD,
Joachim Photiadis, MD
Department of Pediatric Thoracic and Cardiovascular Surgery, German Pediatric Heart Center, Sankt Augustin, Germany
Accepted for publication May 20, 2005.
* Address reprint requests to Dr Asfour, Deutsches Kinderherzzentrum Sankt Augustin, Arnold Janssen-Strasse 29, Sankt Augustin, 53757 Germany (Email: b.asfour{at}asklepios.com).
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Abstract
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We describe a modification of the Children's II operation for hypoplastic left heart syndrome allowing growth potential to be performed without circulatory and cardiac arrest.
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Introduction
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Despite improved surgical technique and management after the modified Norwood operation, early mortality in hypoplastic left heart syndrome remains substantial even at experienced centers [1]. Although severely hypoplastic ascending aorta has reported not to be a risk factor for stage I mortality [2], it still remains a surgical challenge. This has been addressed by the Children's II operation in which the ascending aorta is not involved in the repair, and continuity between the pulmonary trunk and the aortic arch is established using circumferential prosthetic material [3, 4]. This prohibits growth potential for the outflow tract and the aortic arch, and it may result in recurrent arch obstruction. Herein we report a modification of the Children's II operation using only limited patch material allowing growth potential of the aortic arch to be conducted on the beating heart without circulatory arrest.
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Technique
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After median sternotomy and removal of the thymus, a patch of autologous pericardium is harvested. A 3.5 to 4 mm Polytetrafluorethylene shunt (Goretex, W. L. Gore & Associates, Inc, Flagstaff, AZ) is anastomosed to the innominate artery and an 8-French aortic cannula (DLP Medtronic, Düsseldorf, Germany) is inserted into the shunt (Fig 1). After venous cannulation of the right atrial appendage, the patient is cooled on cardiopulmonary bypass (120 to 150 mL/kg/min) to 18°C nasopharyngeal temperature with the pulmonary arteries snared. The descending aorta is cross clamped as well as the aorta distally to the innominate artery (with the left carotid and subclavian artery snared) to maintain coronary and systemic perfusion. Pump flow is adjusted (40 to 60 mL/kg/min) to achieve a mean arterial pressure between 30 and 40 mm Hg of the upper body monitored by a right radial arterial line and 15 to 20 mm Hg of the lower body in case of an additional line in place. Ductal tissue and aortic coarctation is resected. The aortic arch is incised along the lesser curvature. The pulmonary bifurcation is excised only from the posterior part of the pulmonary trunk leaving the anterior part as long as possible (Fig 1). The pulmonary bifurcation is closed with an autologous pericardial patch. A homograft patch is used to augment the aortic arch at the posterior part (Figs 2, 3).
Continuity between the pulmonary trunk and the aortic arch is established by anastomosis of the anterior part of the pulmonary trunk directly to the aortic arch and to the homograft patch in place for the remaining part of the pulmonary trunk (Fig 4). Atrial septectomy is performed through a small right atriotomy with low-flow bypass and venous return removed by intraatrial suckers. Arterial cannula is switched to the neoaorta and the Goretex shunt is anastomosed to the central part of the right pulmonary artery (Fig 4). After discontinuation of cardiopulmonary bypass, modified ultrafiltration is applied. An oximetric catheter (4-French [Edwards Life Sciences, Irvine, CA]) is placed through the common atrium into the superior vena cava for continuous monitoring of systemic venous oxygen saturation [1]. An additional line is placed in the common atrium for pressure monitoring and infusion of inotropic drugs. Perioperative management of hypoplastic left heart syndrome is conducted at our institute as previously published [5].
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Fig 1. Aortic cannulation through a right modified Blalock-Taussig shunt. Resection of the ductus arteriosus and excision of the pulmonary bifurcation was made only from the posterior part of the pulmonary trunk providing a large anterior part. An aortic arch incision was made along the lesser curvature.
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Fig 2. Reconstruction of the pulmonary bifurcation using an autologous pericardial patch, and patch augmentation of the aortic arch for the missing posterior aspect of the pulmonary artery trunk.
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Fig 3. Reconstruction of the pulmonary bifurcation using an autologous pericardial patch, and patch augmentation of the aortic arch for the missing posterior aspect of the pulmonary artery trunk.
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Fig 4. Anastomosis of the anterior part of the pulmonary trunk to the aortic arch and patch anastomosis of the shunt to the right pulmonary artery.
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Comment
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Deep hypothermic circulatory arrest is still widely used to achieve a convenient operative field during the modified Norwood procedure for hypoplastic left heart syndrome. Stage 1 reconstruction can be challenging and time consuming, in cases of associated cardiac defects such as interrupted aortic arch or severely hypoplastic ascending aortas. Prolongation circulatory arrest increases risk of end-organ function and neurologic complications in the short-term and long-term follow-up. Strategies to decrease or avoid circulatory and cardiac arrest should therefore be promoted. Different techniques for continuous systemic perfusion have been reported for the modified Norwood procedure [3, 4, but the use of xenograft material for circumferential anastomosis between the pulmonary trunk and the aortic arch as applied in the latter report carries a substantial risk of late arch obstruction with detrimental effects on long-term function of the single right ventricle. The omission of patch enlargement of the ascending aorta was not associated with increased mortality as reported by others [3].
In conclusion, the surgical technique adopted in this report is safe and is easily applied, which allows excellent exposure and offers convenient time for accurate aortic arch reconstruction. Continuous coronary and systemic perfusion preserving end-organ and cardiac function may have positively influenced overall outcome after the Norwood procedure [6].
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References
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- Tweddell JS, Hoffman GM, Fedderly RT, et al. Phenoxybenzamine improves systemic oxygen delivery after the Norwood procedure Ann Thorac Surg 1999;67:161-167.[Abstract/Free Full Text]
- Gaynor JW, Mahle WT, Cohen MI, et al. Risk factors for mortality after the Norwood procedure Eur J Cardiothorac Surg 2002;22:82-89.[Abstract/Free Full Text]
- Ten-year institutional experience with palliative surgery for hypoplastic left heart syndrome Circulation 1995;92(Suppl II):262-266.[Abstract/Free Full Text]
- Karl T, Sano S, Brawn W, Mee RB. Repair of hypoplastic or interrupted aortic arch via sternotomy J Thorac Cardiovasc Surg 1992;104:688-695.[Abstract]
- Kishimoto H, Kawahira Y, Kawata H, Miura T, Iwai S, Mori T. The modified Norwood palliation on a beating heart J Thorac Cardiovasc Surg 1999;118:1130-1132.[Free Full Text]
- Photiadis J, Urban AE, Sinzobahamvya N, et al. Restrictive left atrial outflow adversely affects outcome after the modified Norwood procedure. Eur J Cardiothoracic Surg 2005 (in press)..
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Abstract
Introduction
