ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Ann Thorac Surg 2008;85:1382-1388. doi:10.1016/j.athoracsur.2007.12.042
© 2008 The Society of Thoracic Surgeons
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Online Discussion
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Christian Pizarro
Christopher D. Derby
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Pizarro, C.
Right arrow Articles by Radtke, W.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Pizarro, C.
Right arrow Articles by Radtke, W.
Related Collections
Right arrow Congenital - cyanotic

Original Articles: Pediatric Cardiac

Stage II Reconstruction After Hybrid Palliation for High-Risk Patients With a Single Ventricle

Christian Pizarro, MD*, Kenneth A. Murdison, MD, Christopher D. Derby, MD, Wolfgang Radtke, MD

The Nemours Cardiac Center; Alfred I. duPont Hospital for Children, Wilmington, Delaware

Accepted for publication December 12, 2007.

* Address correspondence to Dr Pizarro, Alfred I. duPont Hospital for Children, PO Box 269, 1600 Rockland Rd, Wilmington, DE 19899 (Email: cpizarro{at}nemours.org).


Pediatric cardiac surgery: The Annals of Thoracic Surgery CME Program is located online at http://cme.ctsnetjournals.org. To take the CME activity related to this article, you must have either an STS member or an individual non-member subscription to the journal.

 

   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 
Background: The hybrid approach to palliate high-risk neonates with a single ventricle and systemic outflow obstruction continues to gain interest. Despite early success, few data exist regarding the physiologic adequacy of this palliation and the outcome of the stage II reconstruction.

Methods: We reviewed our experience with stage II reconstruction after hybrid palliation in high-risk newborns with hypoplastic left heart syndrome and variants, focusing on the hemodynamic, reintervention, and operative data.

Results: Among 14 patients undergoing hybrid palliation, interstage reinterventions targeted the ductal stent in 2, the atrial septal communication in 3, and the pulmonary artery bands in 1 patient. The median ratio of pulmonary blood flow to systemic blood flow (Qp/Qs) was 0.76, and pulmonary artery pressure was 14 mm Hg. Stage II reconstruction was performed in 8 patients with a median age of 4 months (range, 3.2 to 5.8 months) and a median weight of 4.9 kg (range, 3.7 to 6.0 kg). Median cardiopulmonary bypass time was 124 minutes (range, 95 to 188 minutes). Median time to extubation was 20 hours (range, 9 to 120 hours). Median oxygen saturation at hospital discharge was 79% (range, 78% to 82%). Two perioperative deaths occurred. To date, all hospital survivors are well. Four patients have completed a Fontan.

Conclusions: Stage II reconstruction after hybrid palliation for high-risk neonates carries important morbidity and mortality. A considerable number of reinterventions to optimize the palliated physiology are necessary. This approach can provide appropriate preparation for single-ventricle management while avoiding cardiopulmonary bypass in the neonate. Additional experience and critical risk assessment of the entire strategy are necessary to define its advantages.


This article has been selected for the open discussion forum on the CTSNet Web Site: http://www.ctsnet.org/sections/newsandviews/discussions/index.html

 

The management of congenital heart lesions characterized by the presence of a single ventricle associated with ductal-dependent systemic outflow obstruction has evolved into a sequence of staged interventions, including an extensive surgical reconstruction in the neonatal period. Despite a significant improvement in early survival after stage I Norwood palliation, neonates with associated prematurity, low birth weight, noncardiac conditions, or genetic abnormalities are considered at higher risk, with a stage I mortality of 40% to 50% [1–3]. In addition, concern about the cumulative effect of this intervention on neurodevelopmental function and the inherently unstable physiology these patients exhibit has prompted an ongoing search for novel treatment strategies to improve outcomes [4, 5].

In this scenario, stenting of the ductus arteriosus and banding the branch pulmonary arteries (hybrid approach) has been revisited at various centers with encouraging early results [6–9]. However, few limited data exist on the effectiveness of this palliative approach beyond the initial postoperative period and the suitability of these patients to accomplish a successful cavopulmonary connection.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 Acknowledgments
 References
 
A review of the Nemours Cardiac Center database identified 14 patients with a single ventricle and ductal-dependent systemic outflow obstruction who underwent stenting of the ductus arteriosus and branch pulmonary artery banding as the initial palliative intervention between January 2001 and May 2006. This represents 23% of the total number of patients admitted to our unit with this anatomic lesion, illustrating the selective application of this approach to patients with significant associated comorbidities or genetic or chromosomal abnormalities. Prematurity was defined as a gestational age of less than 35 weeks, and a birth weight of less than 2500 g was considered low. There were three early and two interstage deaths. Due to significant renal dysfunction, stage II reconstruction was not pursued in one additional patient. The remaining 8 patients underwent the stage II surgical reconstruction and constitute the basis of this report.

The study was approved by the local Institutional Review Board (2005-100). Given the retrospective nature of this review and elimination of any identification data, requirement for individual patient consent was waived.

Initial Hybrid Palliation
Technical aspects of the initial hybrid (off-pump) palliation have been reported previously [8]. In summary, branch pulmonary artery banding was performed through a median sternotomy using 3.5-mm Gore-Tex (W. L. Gore, Newark, DE) rings before stent deployment. Tightness of the bands was usually adjusted over a 2.5-mm coronary probe placed alongside the branch pulmonary artery to achieve an arterial oxygen saturation of about 80%. Stenting of the ductus arteriosus was performed through a sheath placed directly into the proximal main pulmonary artery. Stent size and positioning was based on a lateral angiogram through the sheath. Initially, relatively short, 8- x 10-mm premounted balloon-expandable stents (Palmaz-Genesis, Cordis, Miami, FL) were used in 6 patients, whereas recently, longer 8- x 17-mm balloon-expandable (Palmaz-Genesis) and 7- x 20-mm self-expandable (Protégé GPS, ev3, Plymouth, MN) stents have been used in 2 patients. The choice of stent was largely influenced by ductal anatomy and availability.

The adequacy of the atrial septal communication was determined from hemodynamic and echocardiographic data. If the atrial septal communication was thought to be restrictive (mean gradient >5 mm Hg), and according to the nature of this restriction, a balloon atrial septotomy (n = 4) or deployment of an atrial septal stent (n = 2) was performed. Routine echocardiographic assessment was performed on admission to the intensive care unit and weekly until discharged.

Interstage Follow-Up
Outpatient follow-up, including an echocardiogram, was performed at intervals of 2 to 3 weeks or sooner, depending on the clinical condition. All patients were referred for complete hemodynamic, angiographic, and echocardiographic evaluation at 12 weeks, or earlier if a hemodynamic issue was suspected. Because of the technical limitations with direct measurement of pulmonary artery pressure through the bands, and when feasible, mean pulmonary artery pressure was estimated by measurement of pulmonary vein wedge pressure. Combined arch reconstruction and superior cavopulmonary connection was electively scheduled at 16 to 20 weeks of age.

Combined Stage II Surgical Reconstruction
The combined stage II surgical reconstruction consisted of amalgamation of the proximal ascending aorta with the main pulmonary artery, removal or resection of the ductus/stent complex, aortic arch reconstruction, atrial septectomy (with or without removal of atrial septal stent), removal of the branch pulmonary artery bands with arterioplasty, if necessary, and superior cavopulmonary connection.

The surgical reconstruction was performed using deep hypothermic circulatory arrest with periods of intermittent reperfusion in the last 6 patients. Myocardial protection consisted of single-dose crystalloid cardioplegia. Aortic arch reconstruction was performed after removal ("endarterectomy-like") of the stent or en bloc resection of the ductus arteriosus/proximal descending aorta complex (Fig 1). In the latter case, ample mobilization of the descending aorta, aortic arch, and brachiocephalic vessels was necessary to achieve the reconstruction without tension. Reconstruction or reimplantation of the distal arch/ductus confluence was performed depending on the integrity of the distal arch orifice, commonly straddled by the ductal stent. Amalgamation of the proximal main pulmonary artery and ascending aorta was performed to complete the neoaortic reconstruction using a pulmonary artery homograft patch in all cases.


Figure 1
View larger version (55K):
[in this window]
[in a new window]

  		Fig 1. (A) Pre-stage II illustration shows the bilateral pulmonary artery banding and ductal stenting in place. (B) Excision of the ductal stent en block in preparation for aortic arch and neoaortic reconstruction. Patch closure of distal main pulmonary artery as well as proximal end of the ductus. Branch pulmonary arteries bands have been removed. Note the mild distortion at the band sites. (C) Endarterectomy-like removal of the ductal stent through the transected distal main pulmonary artery. As shown in the illustration, depending on the time elapsed since the initial palliation, partial removal of the intima and part of the media is common, without complete disruption of the vascular wall, therefore reducing the magnitude of the reconstruction. (D) Stage II reconstruction.

 
After removal of the bands, the branch pulmonary arteries were inspected to assess the need for additional reconstruction, which included patch augmentation with a pulmonary artery homograft. Before the superior cavopulmonary connection was completed, an atrial septectomy or removal of the atrial septal stent, or both, was performed if necessary.

Postoperative management was aimed at early extubation and targeted a PaO 2 exceeding 35 mm Hg. Severe and persistent hypoxemia unresponsive to volume expansion, permissive hypercapnia, and inspired nitric oxide were the criteria for takedown of the cavopulmonary connection to a systemic–pulmonary artery shunt.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 Acknowledgments
 References
 
Hemodynamic and reintervention data before stage II reconstruction are reported in Table 1. Hemodynamic evaluation demonstrated a median pulmonary blood flow to systemic blood flow (Qp/Qs) ratio of 0.76 (range, 0.25 to 1.8). Branch pulmonary artery pressures were generally appropriate, with a median value of 14 mm Hg (range, 10 to 37 mm Hg); the highest value was observed in a patient with inadequate banding on the left pulmonary artery. A pressure gradient across the ductal stent developed over time in 6 of 8 patients, and when this pressure gradient exceeded 25 mm Hg, it was addressed by balloon angioplasty (n = 2) or at the time of stage II reconstruction (n = 2). Three patients with a restrictive atrial septal defect underwent static balloon dilatation, followed in 2 patients by deployment of an interatrial stent. A fourth patient showed rapid development of a pressure gradient across the atrial septal defect after 3 months, which was relieved at the time of surgical reconstruction. Echocardiographic assessment demonstrated qualitatively normal ventricular function and absence of atrioventricular valve or semilunar valve regurgitation in all patients.


View this table:
[in this window]
[in a new window]

  		Table 1 Hemodynamic Data and Reinterventions Before Stage II
 
Median age at stage II reconstruction was 4 months (range, 3.2 to 5.8 months), and the median weight was 4.9 kg (range, 3.7 to 6.0 kg), which corresponds to the 15th percentile or less (Table 2). Owing to increased gradient across the ductal stent or atrial septal communication, 2 patients underwent stage II reconstruction earlier than planned. The ductus arteriosus was excised en bloc with the stent in 5 patients; in the remaining 3 the stent was "peeled-off," leaving the distal arch and proximal descending aorta complex in situ. Balloon-expandable stents typically did not extend into the main pulmonary artery or beyond the origin of the aortic arch and therefore facilitated removal or resection and aortic arch reconstruction. Self-expanding stents commonly extended into the main pulmonary artery and thoracic aorta, at least partially covering the confluence of the aortic arch. Although largely preventing ductal coarctation, these stents resulted in greater anatomic disruption and increased the extent of arch reconstruction.


View this table:
[in this window]
[in a new window]

  		Table 2 Clinical Experience
 
Reconstruction of the left pulmonary artery was performed in 2 patients. In 1 patient, an intimal flap occluded the lumen, resulting in diffuse hypoplasia; another patient had 2 longitudinal tears originating in the area of the band. Arch obstruction was seen in 2 patients; this was recognized intraoperatively in 1 patient with unusual ductal anatomy and repaired during the stage II reconstruction. In another case, a recurrent distal arch obstruction was surgically repaired after two failed balloon angioplasties 3 to 7 months after stage II reconstruction.

The median duration of cardiopulmonary bypass was 124 minutes (range, 95 to 188 minutes), deep hypothermic circulatory arrest was 65.1 minutes (range, 39 to 78 minutes), and myocardial ischemia was 82.6 minutes (range, 67 to 105 minutes). The median duration of mechanical ventilation was 20 hours (range 9 to 120 hours), but was significantly prolonged in a patient with severe left lung hypoplasia and postoperative anasarca. The median preoperative lactate level was 1.5 mmol/L (range, 1.3 to 3.8 mmol/L), peaked at 7.2 mmol/L (range, 3.1 to 10.7 mmol/L) in the immediate postoperative period, and returned to normal within 18 hours.

Three patients exhibited transient seizure activity in the immediate postoperative period and recovered without evidence of neurologic deficit by the time of discharge. Intracranial hemorrhage occurred in 1 patient. Important and persistent hypoxemia was associated with two of these neurologic events. The median hospital stay was 26 days (range, 6 to 105 days), but was significantly prolonged in 3 patients owing to postoperative supraventricular dysrhythmias. At the time of discharge, median oxygen saturation was 79% (range, 78% to 82%), and all patients exhibited normal sinus rhythm.

There were two operative deaths. One patient who died had complex transposition and aortic arch hypoplasia and sustained a cerebral hemorrhage in the perioperative period, and the second patient had significant bleeding associated with hypoxemia as a consequence of disruption of the left pulmonary artery upon removal of the band. At a median follow-up of 33 months (range, 15 to 81 months), there was one trauma-related late death. One patient awaits Fontan, and 4 others have undergone Fontan completion and remain well.


   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
Acknowledgments
 References
 
Despite increasing application of a hybrid approach to manage newborns considered at high-risk for stage I Norwood palliation, limited data exist to confirm that this approach can provide the necessary hemodynamic conditions for a successful cavopulmonary connection. Since Akintuerk and colleagues [6] reported the combined stage II surgical reconstruction with success, the pathway from initial hybrid palliation leading towards a Fontan circulation has become readily apparent and the approach continues to gain interest. To date, comprehensive and detailed data on subsequent palliation are scarce.

Hemodynamic assessment after hybrid palliation showed reasonable preservation of ventricular function, a balance of the systemic and pulmonary circulations with comparatively less volume load than conventional surgical palliation, and in most cases, reasonable protection of the pulmonary vascular bed. A pressure gradient across the ductal stent or atrial septal communication was commonly detected and prompted catheter intervention or early surgery, as has been noted in other series [6, 7, 9]. Although the pressure gradient across the ductus was commonly related to incomplete stenting of ductal tissue early in this experience, the use of longer stents has not completely eliminated the development of progressive obstruction, commonly associated with accumulation of neointimal tissue, particularly in the presence of unusual ductal anatomy.

Adequacy of the atrial septal communication had a variable course depending on anatomic features such as true deficiency of septum primum, posterior deviation of the atrial septum, and antegrade flow through the left heart. These factors played an important role influencing the impact of a restriction at the level of the atrial septal communication and the technical aspects of establishing an unobstructed communication. Our experience echoes the significant learning curve and the considerable number of interstage reinterventions before stage II, as previously reported [6, 7, 9].

Although early transition to a combined stage II reconstruction can be applied to shorten the vulnerable interstage period, reducing the duration of initial palliation to no more than 12 to 16 weeks after a hybrid approach, this has not completely eliminated the need to address important hemodynamic issues. In this cohort, 3 patients transitioned to stage II earlier than the scheduled 4 months due to recurrent hemodynamic issues, including 1 patient in whom the cavopulmonary connection was taken down to a systemic–pulmonary artery shunt due to severe hypoxemia.

Considering the fact that early stage II is usually associated with lower arterial oxygen saturation and prolonged hospital course [10], the presence of a suboptimal palliated state could easily lead to increased morbidity and a poor outcome. This reinforces the concept that strict patient surveillance is essential to detect and promptly address such problems, restoring the optimal palliated physiology necessary to achieve a successful cavopulmonary connection. In this scenario, an intervention to effectively restore optimal physiologic conditions should be carefully balanced against early transition to a second stage and the inherent risk of important hypoxemia due to a failed superior cavopulmonary connection.

The idea that the hybrid approach could allow time for the small patient to gain weight before the extensive surgical intervention appeared to be only applicable to premature newborns. The difficulties with growth and development observed in the post-Norwood population were also observed in these patients, who at the time of operation were well below the 15th percentile for weight, despite appropriate caloric intake. This should not constitute an unexpected finding, particularly in a population who exhibited important comorbidities and in some cases a residual hemodynamic burden.

Stage II reconstruction after hybrid palliation represents a formidable technical challenge involving the reconstruction of the aortic arch, proximal neoaorta, and superior cavopulmonary connection. The complexity of this procedure can increase even more if repair of the branch pulmonary arteries, distorted by the placement of bands, and atrial septectomy are necessary. A lengthy reoperative procedure, the common presence of ventricular hypertrophy, and flow disturbance in the brachiocephalic vessels require effective myocardial as well as neuroprotection.

Although periods of circulatory arrest were minimized and intermittent reperfusion was commonly used during arch reconstruction in this cohort, neurologic events remained the most common postoperative issue. The exact pathophysiology behind these events is likely multifactorial and possibly relates to the magnitude of the surgery and the use of circulatory arrest for the arch and the hemi-Fontan-type reconstruction. In addition, the presence of postoperative hypoxemia, cerebral venous congestion, and decreased cerebral blood flow due to abnormal cerebrovascular autoregulation after a period of deep hypothermia and cerebral ischemia [4] could have contributed to a cumulative insult during the immediate perioperative period. It should be noted that the association of hypoxemia and cerebral venous congestions could lead to a neurologic dysfunction, considering the reciprocal relationship between cerebral and pulmonary feedback loops after superior cavopulmonary connection [11]; therefore, any efforts to increase oxygenation can only occur at the expense of cerebral vasodilation and increased cerebral venous pressure.

The high incidence of neurologic events prompted us to significantly reduce the use of circulatory arrest, increase the periods of intermittent reperfusion, and consider early takedown of the superior cavopulmonary connection to a systemic–pulmonary artery shunt any time important hypoxemia could be mitigated with usual medical measures. Although the use of regional cerebral perfusion could intuitively appear to offer a solution to the issue of neurologic morbidity, this has not been associated with improvement in neurodevelopmental function, as shown by the only randomized clinical trial to date [12]. In fact, the tendency to worse point estimates with the use of this strategy could be a function of increased cerebrovascular resistance and cerebral edema leading to hypoxemia. Development of improved perfusion strategies aimed at preservation of cerebral autoregulation could have a favorable effect by virtue of lowering cerebrovascular resistance combined with the concomitant increase in cerebral oxygenation in these patients.

Reconstruction of the aortic arch was largely influenced by features of the stenting of the ductus. When the ductus was excised, extensive mobilization of the brachiocephalic vessels and descending aorta was required to bridge the long gap between the proximal main pulmonary artery and the descending thoracic aorta during the reconstruction. In the absence of a true coarctation shelf, when the stent was not straddling the opening of the distal arch into the ductus, the distal resection line usually preserved the distal arch–thoracic aorta continuity. This facilitated the repair and reduced the potential for technical problems, including compression of the left mainstem bronchus and phrenic injury, among others.

Depending on the elapsed time and the endovascular reaction after stent deployment, a stent extending into the thoracic aorta was removed at least partially, leaving adventitia and portions of the media intact ("endarterectomy-like"), thus reducing the magnitude of the repair. Development of recurrent obstruction observed in 2 patients was not related to removal or excision of the stent and resulted in a rate of reintervention similar to that reported by other centers [6] or after conventional Norwood reconstruction.

Our experience confirms the observation that after band removal, the branch pulmonary arteries reexpanded in most cases, leaving no evidence of residual stenosis due to intimal proliferation. This may be in part attributed to the use of polytetrafluoroethylene bands, which appear to elicit a minimal inflammatory reaction in the vascular wall. Because most patients had a hemi-Fontan connection, the central pulmonary arteries were routinely patch augmented; therefore, a separate pulmonary artery patch reconstruction was not necessary.

Owing to the hemodynamic advantages of a superior cavopulmonary connection [13], it was not unexpected that despite the extensive surgery, the postoperative period of these patients was characterized by excellent peripheral perfusion, prompt normalization of lactate levels, and a short duration of mechanical ventilatory support. Takedown of the superior cavopulmonary connection to a systemic–pulmonary artery shunt occurred in 1 patient with severe left lung hypoplasia and persistent postoperative hypoxemia. It is possible that despite the presence of appropriate preoperative hemodynamic conditions, a prolonged period of cardiopulmonary bypass could have contributed to a significant increase in pulmonary vascular reactivity [13–16].

Our results demonstrate that stage II reconstruction still carries a significant morbidity and mortality in a cohort of patients with serious comorbidities and residual hemodynamic issues somehow related to the incremental technical challenge of implementing this strategy among very small and premature newborns. This observation concurs with the report by Bacha and colleagues [9] on the management of high-risk patients with hypoplastic left heart syndrome, and is not too dissimilar when this strategy has been applied to patients otherwise considered good candidates for conventional surgical palliation [7, 17]. At present, the risk for death is difficult to define, given the limited experience, the small number of patients, and the variability of clinical characteristics among series, including the use of this strategy to manage patients who ultimately underwent cardiac transplantation or biventricular repair [17].

The extensive surgical reconstruction and the physiologic requirements for a successful cavopulmonary connection demand an effective preoperative palliation and a flawless technical exercise to achieve a successful outcome and reduce the morbidity and mortality associated with this approach. In the absence of these preoperative and operative conditions, the possibility to follow the initial hybrid palliation with a conventional Norwood procedure should be considered.

Completion of a Fontan circulation in 4 of 6 stage II survivors confirms the notion that this palliative approach can provide the hemodynamic conditions necessary to achieve the ultimate physiologic goal for patients with a single ventricle. Although these results are encouraging, the morbidity and mortality associated with the stage II surgical reconstruction should be factored in the overall risk associated with this hybrid approach. A comprehensive evaluation of the risks and morbidity from the time of initial palliation leading to the Fontan circulation will be necessary before a meaningful comparison with the conventional surgical palliation can be made. As the hybrid approach continues to evolve, it should be expected that additional experience, procedural refinement, and follow-up would help to define its true indications and potential benefits, particularly with regards to neurodevelopmental outcome.

The retrospective nature of this study, the small number of subjects, and the lack of a control group do not allow meaningful statistical analysis or the comparison with alternative management options. Owing to the consistent and uniform operative management of these patients, no inferences could be drawn about potentially important determinants of outcome such as perfusion strategy, timing of surgery, type of arch reconstruction, or superior cavopulmonary connection, among others. These important limitations do not allow placement of the outcomes after the hybrid approach within the context of current surgical palliation.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
References
 
We would like to thank Drs William I. Norwood and John D. Murphy for their contribution in the care of some of these patients, and Carol Prospero for her assistance with data collection and the preparation of this work.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Ashburn DA, McCrindle BW, Tchervenkov CI, et al. Outcomes after the Norwood operation in neonates with critical aortic stenosis or aortic valve atresia J Thorac Cardiovasc Surg 2003;125:1070-1082.[Abstract/Free Full Text]
  2. 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]
  3. Pizarro C, Malec E, Maher KO, et al. Right ventricle to pulmonary artery conduit improves outcome after stage I Norwood for hypoplastic left heart syndrome Circulation 2003;108(suppl):II155-II160.[Medline]
  4. Tsui SS, Schultz JM, Shen I, Ungerleider RM. Postoperative hypoxemia exacerbates potential brain injury after deep hypothermic circulatory arrest Ann Thorac Surg 2004;78:188-196.[Abstract/Free Full Text]
  5. Galli KK, Zimmerman RA, Jarvik GP, et al. Periventricular leukomalacia is common after neonatal cardiac surgery J Thorac Cardiovasc Surg 2004;127:692-704.[Abstract/Free Full Text]
  6. Akintuerk H, Michel-Behnke I, Valeske K, et al. Stenting of the arterial duct and banding of the pulmonary arteries: basis of a combined Norwood Stage I and II repair in hypoplastic left heart Circulation 2002;105:1099-1103.[Abstract/Free Full Text]
  7. Galantowicz M, Cheatham JP. Lessons learned from the development of a new hybrid strategy for the management of hypoplastic left heart syndrome Pediatr Cardiol 2005;26:190-199.[Medline]
  8. Pizarro C, Murdison KA. Off-pump palliation for hypoplastic left heart syndrome: surgical approach Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2005;7:66-71.
  9. Bacha EA, Daves S, Hardin J, et al. Single-ventricle palliation for high-risk neonates: the emergence of an alternative hybrid stage I strategy J Thorac Cardiovasc Surg 2006;131:163-171.[Abstract/Free Full Text]
  10. Jaquiss RD, Ghanayem NS, Hoffman GM, et al. Early cavopulmonary anastomosis in very young infants after Norwood procedure: impact on oxygenation, resource utilization, and mortality J Thorac Cardiovasc Surg 2004;127:982-989.[Abstract/Free Full Text]
  11. Fogel MA, Durning S, Wernovsky G, Polluck AN, Gaynor JW, Nicolson S. Brain versus lung: hierarchy of feedback loops in single-ventricle patients with superior cavopulmonary connection Circulation 2004;110(11 Suppl 1):II147-II152.[Medline]
  12. Goldberg CS, Bove EL, Devaney EJ, et al. A randomized clinical trial of regional cerebral perfusion versus deep hypothermic circulatory arrest: Outcomes for infants with functional single ventricle J Thorac Cardiovasc Surg 2007;133:880e1-887e1.
  13. Jacobs ML, Rychik J, Rome JJ, et al. Early reduction of the volume work of the single ventricle: the hemi-Fontan operation Ann Thorac Surg 1996;62:456-461.[Abstract/Free Full Text]
  14. Skaryak LA, Lodge AJ, Kirshbom PM, et al. Low-flow cardiopulmonary bypass produces greater pulmonary dysfunction than circulatory arrest Ann Thorac Surg 1996;62:1284-1288.[Abstract/Free Full Text]
  15. Kirshbom PM, Jacobs MT, Tsui SS, et al. Effects of cardiopulmonary bypass and circulatory arrest on endothelium-dependent vasodilation in the lung J Thorac Cardiovasc Surg 1996;111:1248-1256.[Abstract/Free Full Text]
  16. Schultz JM, Karamlou T, Swanson J, Shen I, Ungerleider RM. Hypothermic low-flow cardiopulmonary bypass impairs pulmonary and right ventricular function more than circulatory arrest Ann Thorac Surg 2006;81:474-480.[Abstract/Free Full Text]
  17. Michel-Behnke I, Akintuerk H, Marquardt I, et al. Stenting of the ductus arteriosus and banding of the pulmonary arteries: basis for various surgical strategies in newborns with multiple left heart obstructive lesions Heart 2003;89:645-650.[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 Eur J Cardiothorac SurgHome page
A. Carotti
Postoperative neurodevelopmental outcome of patients with hypoplastic left heart complex: hybrid versus Norwood strategy
Eur J Cardiothorac Surg, July 1, 2012; 42(1): 40 - 41.
[Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
T. Cotts, J. Hirsch, M. Thorne, and R. Gajarski
Tracheostomy after pediatric cardiac surgery: Frequency, indications, and outcomes
J. Thorac. Cardiovasc. Surg., February 1, 2011; 141(2): 413 - 418.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
N. S. Ghanayem, G. M. Hoffman, K. A. Mussatto, M. A. Frommelt, J. R. Cava, M. E. Mitchell, and J. S. Tweddell
Perioperative monitoring in high-risk infants after stage 1 palliation of univentricular congenital heart disease
J. Thorac. Cardiovasc. Surg., October 1, 2010; 140(4): 857 - 863.
[Abstract] [Full Text] [PDF]

Home page
 World Journal for Pediatric and Congenital Heart SurgeryHome page
R. A. Jonas
Why I Believe the Hybrid Norwood Is Inferior to the Norwood/Sano Procedure
World Journal for Pediatric and Congenital Heart Surgery, July 1, 2010; 1(2): 161 - 162.
[Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
O. Honjo, L. N. Benson, H. E. Mewhort, D. Predescu, H. Holtby, G. S. Van Arsdell, and C. A. Caldarone
Clinical Outcomes, Program Evolution, and Pulmonary Artery Growth in Single Ventricle Palliation Using Hybrid and Norwood Palliative Strategies
Ann. Thorac. Surg., June 1, 2009; 87(6): 1885 - 1893.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Online Discussion
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Christian Pizarro
Christopher D. Derby
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Pizarro, C.
Right arrow Articles by Radtke, W.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Pizarro, C.
Right arrow Articles by Radtke, W.
Related Collections
Right arrow Congenital - cyanotic

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS