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HOW I DO IT ? MODIFIED NORWOOD’S OPERATION. VICHAI BENJACHOLAMAS, MD . CHULALONGKORN HOSPITAL. HYPOPLASTIC LEFT HEART SYNDROME. Mitral valve atresia or stenosis Small left ventricle Aortic valve atresia or stenosis Small ascending aorta Various degree of aortic arch obstruction.

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how i do it modified norwood s operation

HOW I DO IT ?MODIFIED NORWOOD’S OPERATION

VICHAI BENJACHOLAMAS, MD.

CHULALONGKORN HOSPITAL

hypoplastic left heart syndrome
HYPOPLASTIC LEFT HEART SYNDROME
  • Mitral valve atresia or stenosis
  • Small left ventricle
  • Aortic valve atresia or stenosis
  • Small ascending aorta
  • Various degree of aortic arch obstruction
hypoplastic left heart syndrome4
HYPOPLASTIC LEFT HEART SYNDROME
  • Perop. Management
    • PGE-1  open PDA
    • Avoid oxygen
    • Correct acidosis
    • Inotrope
    • Diuretic
    • Intubation if neccessary
hypoplastic left heart syndrome5
HYPOPLASTIC LEFT HEART SYNDROME

Hybrid procedure

VS

Modified Norwood’s operation

hypoplastic left heart syndrome6
HYPOPLASTIC LEFT HEART SYNDROME

Hybrid procedure

  • PDA stenting
  • Bilateral PA banding
  • +/- balloon atrial septostomy
hypoplastic left heart syndrome7
HYPOPLASTIC LEFT HEART SYNDROME

Modified Norwood’s operation

  • Aortic and arch reconstruction with/without homograft
  • Atrial septectomy
  • Shunt to pulmonary artery

BT shunt or Sano shunt

hypoplastic left heart syndrome8
HYPOPLASTIC LEFT HEART SYNDROME
  • Timing for Norwood’s operation

AGE < = 10 days

materials and methods

MATERIALS AND METHODS

August 1996- November 2008

Modified Norwood’s Operation

was performed in 26 neonates

materials and methods10

MATERIALS AND METHODS

AGE

3 - 75 days

( median 11 days )

materials and methods11

MATERIALS AND METHODS

WEIGHT

2,000 - 4,200 grams

( median 2,850 grams )

materials and methods12

MATERIALS AND METHODS

ASCENDING AORTA DIAMETER

2 - 7 mm.

( median 2.5 mm. )

surgical technique
SURGICAL TECHNIQUE
  • Operate under cardiopulmonary bypass

with profound hypothermia

  • Arterial cannulation

- at MPA for first 10 patients

- at Goretex graft to right bracheo-

cephalic artery for last 16 patients

  • Venous cannulation with single venous at

Rt. Atrial appendage

surgical technique16
SURGICAL TECHNIQUE
  • Resected PDA tissue and aortic ischmus
  • Arch reconstruction with MPA or homograft
  • Atrial septectomy
  • Rt. Modified Blalock-Taussig shunt
surgical technique20
SURGICAL TECHNIQUE

Arch reconstruction with

native MPA = 4 patients

Homograft = 22 patients

aortic = 3/22 patients

pulmonic = 19/22 patients

surgical technique22
SURGICAL TECHNIQUE

BT Shunt size selection

3.5 mm. for Body weight <= 3.5 kg.

4.0 mm. for Body weight > 3.5 kg.

surgical technique23
SURGICAL TECHNIQUE

MedianCPB time

=96 min. (51-163 min.)MedianDHCA time

=66 min. (51-97 min.)

Median CPB+DHCA time

=159 min. (125-216 min.)

surgical technique24
SURGICAL TECHNIQUE

BT shunt

VS

Sano shunt

surgical technique25
SURGICAL TECHNIQUE

Advantages/disadvantages of the modified Blalock-Taussig shunt

surgical technique26
SURGICAL TECHNIQUE

Advantages/disadvantages of the Sano shunt

surgical technique27
SURGICAL TECHNIQUE

Sano shunt benefit in AA, MA

postoperative care
POSTOPERATIVE CARE

RULE OF FOURTY (40)

- Fi O2 ~ 0.40

- Pa CO 2 ~ 40 mmHg.

- Pa O2 ~ 40 mmHg.

- Hct. ~ 40 %

postoperative care29
POSTOPERATIVE CARE

Oxygen saturation

after extubation

78 - 85 % ( average 82 % )

results
RESULTS

Hospital mortality was 23.1%(6/26)

(within 30 days)

DOT 3/6

Survival rate = 76.9 % (20/26)

results31
RESULTS

Mortality rate by arch reconstruction technique

  • Autologous tissue

mortality rate = 50 % (2/4)

survival rate = 50 % (2/4)

  • Homograft patch

mortality rate = 18.2 % (4/22)

survival rate = 81.8 % (18/22)

discussion
DISCUSSION

PRE-OPERATION

- Need experienced cardiologist to take

care the patient before operation

- Not to put ET tube in the patient

- Stabilize cardiovascular, no acidosis

discussion34
DISCUSSION

INTRA-OPERATION

- Arch reconstruction with homograft seem

to be better ( smooth postoperative care,

early extubation and no late coarctation,

especially pulmonary homograft)

- Select proper shunt size to maintain

O2 saturation ~75-80 %

discussion35
DISCUSSION

POST-OPERATION

- Early catheterization at either

5 or 6 mo.old or progress cyanosis

- Change to BCP shunt before out-growth

of the BT shunt

summary
SUMMARY

The treatment of hypoplastic left heart syndrome need a lot effort. Despite good equipment, it needs very good team include neonatal cardiologist, neonatal cardiac anesthetist, neonatal cardiac surgeon, well- trained scrub nurse, keen perfusionist, and keen ICU nurse.