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Ann Thorac Surg 2006;82:1169
© 2006 The Society of Thoracic Surgeons

Correspondence

Reply

John J. Nigro, MD, MS, Joseph Graziano, MD

Saint Joseph's Hospital and Medical Center, Cardiothoracic Surgery, 500 West Thomas Rd, Suite 680, Phoenix, AZ 85013

(Email: john.nigro{at}chw.edu).

To the Editor:

We appreciate the Munich [1] group's response to our article [2] and their experience with proximal conduit obstruction after right ventricle (RV) to pulmonary artery (PA) modified Norwood procedure. The angiograms that they have submitted clearly delineate the proximal conduit obstruction (intimal hyperplasia that emanates from the endocardium), which we have described in our report [2] These angiograms, obtained on the other side of the planet, confirm that this process (intimal hyperplasia) is a universal potential complication of RV-PA conduit, and is probably not directly due to individual variations in conduit placement. We also re-emphasize as well as the Munich authors, that the critical time period for this to occur is 2 to 4 months post-Norwood, and it can result in the dilemma of how to provide adequate pulmonary blood flow in a child not ready for a cavopulmonary anastamosis [2–7]. Dehydration and hypercontractility potentiate the effect of proximal conduit stenosis, and both the use of volume replacement and afterload manipulation may help initial stabilization of these patients [2, 7]. Cyanosis can be a sentinel sign of proximal conduit obstruction, and when the proximal conduit is obstructed, an intervention (ie, cavopulmonary anastamosis, systemic to pulmonary shunt) is required to provide for secure pulmonary blood-flow [2–7]. Proximal conduit stenting seems effective in the hands of the Munich group, and they are to be commended for appreciating the significance of proximal conduit obstruction and successful implementation of a novel solution. We continue to believe that most reshunting procedures can be accomplished without "potential negative effects on myocardial function," and without more detailed information about the stenting technique and the Munich experience, we remain reluctant to advocate the placement of a catheter and subsequent stent deployment across the highly stenosed obligatory source of pulmonary blood flow in these patients.


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 References
 

  1. Eicken A, Schreiber C. Stenting of a stenosed Sano shunt after palliation in hypoplastic left heart syndrome (letter) Ann Thorac Surg 2006;82:1168-1169.[Free Full Text]
  2. Nigro JJ, Bart RD, Derby CD, Sklansky MS, Starnes VA. Proximal conduit obstruction after Sano modified Norwood procedure Ann Thorac Surg 2005;80:1924-1928.[Abstract/Free Full Text]
  3. Eicken A, Sebening W, Genz T, Schreiber C, Hess J. Stenting of a stenosed sano shunt in a neonate with hypoplastic left heart syndrome Pediatr Cardiol 2005:18.
  4. Sano S, Ishino K, Kawada M, et al. Right ventricle-pulmonary artery shunt in first-stage palliation of hypoplastic left heart syndrome J Thorac Cardiovasc Surg 2003;126:504-509.[Abstract/Free Full Text]
  5. Sano S, Ishino K, Kawada M, Honjo O. Right ventricle-pulmonary artery shunt in first-stage palliation of hypoplastic left heart syndrome Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2004;7:22-31.[Medline]
  6. Sano S, Ishino K, Kado H, et al. Outcome of right ventricle-to-pulmonary artery shunt in first-stage palliation of hypoplastic left heart syndromea multi-institutional study. Ann Thorac Surg 2004;78:1951-1957.[Abstract/Free Full Text]
  7. Simsic JM, Cuadrado A, Kirshbom PM, et al. Novel management strategy for severe cyanosis after Sano modification of the Norwood procedure J Thorac Cardiovasc Surg 2005;129:1450-1451.[Free Full Text]

Related Article

Stenting of a Stenosed Sano Shunt After Palliation in Hypoplastic Left Heart Syndrome
Andreas Eicken and Christian Schreiber
Ann. Thorac. Surg. 2006 82: 1168-1169. [Extract] [Full Text] [PDF]




This Article
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