Coarctectomy combined with an interdigitating arch reconstruction results in a lower incidence of recurrent arch obstruction after the Norwood procedure than coarctectomy alone

Interdigitating Technique for Repair of Aortic Arch Obstruction to Reduce Reintervention Rates

BACKGROUND

The incidence of reintervention for aortic arch obstruction is 5% to 14% after coarctation or hypoplastic aortic arch repair and 25% after the Norwood procedure. Institutional practice review indicated higher than reported reintervention rates. Our aim was to assess the impact of an interdigitating reconstruction technique on reintervention rates for recurrent aortic arch obstruction.

METHODS

Children (<18 years) were included if they had undergone aortic arch reconstruction by sternotomy or the Norwood procedure. Three surgeons participated in the intervention with staggered rollout dates between June 2017 and January 2019, with the study ending December 2020 and review for reinterventions ending February 2022. Preintervention cohorts represented patients who underwent aortic arch reconstructions with patch augmentation, and postintervention cohorts represented patients who underwent an interdigitating reconstruction technique. Reinterventions by cardiac catheterization or operation were measured within 1 year of initial operation. Wilcoxon rank sum and χ2 tests were used to compare preintervention and postintervention cohorts.

RESULTS

Overall, 237 patients were included for participation in this study, with 84 patients in the preintervention cohort and 153 in the postintervention cohort. Patients undergoing the Norwood procedure represented 30% (n = 25) of the retrospective cohort and 35% (n = 53) of the intervention cohort. Overall reinterventions were significantly decreased after the study intervention from 31% (n = 26/84) to 13% (n = 20/153; P < .001). Reintervention rates were decreased for each intervention cohort: aortic arch hypoplasia (24% [n = 14/59] vs 10% [n = 10/100]; P = .019) and Norwood procedure (48% [n = 12/25] vs 19% [n = 10/53]; P = .008).

CONCLUSIONS

The interdigitating reconstruction technique for obstructive aortic arch lesions was successfully implemented and is associated with a decrease in reinterventions.

Journey Toward Improved Long-Term Outcomes After Norwood-Sano Procedure: Focus on the Aortic Arch Reconstruction

The disadvantage of right ventricle-to-pulmonary artery (RV-PA) shunt is the need for more unplanned interventions to address stenosis in the shunt or branch pulmonary arteries, as compared to the modified Blalock-Taussig shunt group. Ring-enforced RV-PA PTFE conduit and dunk technique minimized these complications and right ventricle (RV) damage. Aortic arch obstruction increases afterload and leads to ventricular dysfunction and tricuspid regurgitation; therefore, most surgeons prefer to use homograft, autologous pericardium, or bovine pericardium to reconstruct the neoaorta. Artificial materials decrease the elastic properties, increase wall stiffness, and decrease the distensibility of the aorta; and as a result, RV function gradually deteriorates. This inelastic reconstructed aorta may be one of the reasons why long-term outcomes after the Fontan procedure are worse in hypoplastic left heart syndrome (HLHS) patients, in comparison to non-HLHS. Reconstruction of the neoaorta without any patch materials, or at least techniques that largely minimize the use of non-autologous materials, will offer a further refinement of our ability to optimize ventriculoarterial coupling and thereby long-term RV function.

Incidence of and Risk Factors for Aortic Arch Interventions After the Comprehensive Stage II Procedure for Hypoplastic Left Heart Syndrome

Minimal data exist about the incidence and risk factors for arch intervention after comprehensive stage II (CSII). Goal of this study was to document incidence of arch interventions after CSII and determine if any differences existed between those who underwent an arch intervention (aiCSII) versus those did not have an intervention. Single-center retrospective chart review of all hypoplastic left heart syndrome patients who underwent a CSII between 6/1/2005 and 2/1/2020 was performed. Univariate analysis was conducted in addition to principal components analysis (PCA). One hundred patients were evaluated. Sixteen patients underwent 24 arch interventions. Age at initial arch reintervention was 1.3 ± 1.2 years (median 1.0 years, range 0.5-2.2 years). Univariate analysis showed that the aiCSII group were more likely to be female, to have had a retrograde arch intervention post-hybrid procedure, and to be younger at time of CSII. On echocardiograms, aiCSII group had significantly higher pre-CSII patent ductus arteriosus velocities, arch velocities on their 1st post-operative and discharge study post-CSII, and arch velocities pre-Fontan. Gradients were higher in the aiCSII via pre-Fontan catheterization. With PCA, echocardiographic and catheterization data remained significantly associated with aiCSII versus those who did not undergo an arch intervention (OR = 4.5 (1.9, 19.8), p = 0.008). Incidence of arch intervention post-CSII was 16%. Echocardiographic arch velocities during the CSII hospitalization were the strongest predictors for subsequent aortic arch interventions. Further studies are needed to determine any modifiable variables that may reduce the incidence of arch interventions.

Does the size of pulmonary artery impact on recoarctation of the aorta after the Norwood procedure without patch?

OBJECTIVES

This study aimed to evaluate whether recoarctation of the aorta (reCoA) after the Norwood procedure for hypoplastic left heart syndrome correlates with pre- and postoperative anatomic factors.

METHODS

This retrospective study included 48 patients who underwent Norwood procedure with right ventricle-to-pulmonary artery conduit between 2009 and 2017. Anatomical factors such as preoperative length, diameter of the main pulmonary artery (MPA), and postoperative neoaortic arch angle stratified by arch reconstruction technique were analysed using the receiver operating characteristic analysis.

RESULTS

Eleven patients needed surgical intervention for reCoA at stage 2. Out of the 30 patients who underwent direct anastomosis during arch reconstruction, 7 developed reCoA. Seven patients received the full patch augmentation (patch augmentation for both lesser and greater curvatures) and were all spared from reCoA. Among the patients who had direct anastomosis, the preoperative MPA length was correlated with the postoperative arch angle (P = 0.021) and was associated with the occurrence of reCoA (P = 0.002) and the best cutoff value for MPA length was 10 mm. The postoperative arch angle was also correlated with the incidence of reCoA (P < 0.001) and was larger in patients who underwent the full patch augmentation than in patients who had direct anastomosis (126° vs 112°, P = 0.005) despite comparable MPA length.

CONCLUSIONS

ReCoA after the Norwood procedure correlates with MPA length when a direct anastomosis was used. Direct anastomosis can be considered in patients with a longer preoperative MPA. In other cases, the full patch augmentation should be considered for obtaining a large and smooth neoaortic arch.

Chimney reconstruction provides a wider subaortic space and reduces the risk of pulmonary artery compression in the Norwood-type aortic arch reconstruction without patch supplementation

OBJECTIVES

Pulmonary artery (PA) compression by the neoaorta is a serious complication after the Norwood-type palliation (NP) for hypoplastic left heart syndrome. Either excess patch tailoring or limited use of autologous tissue may cause narrowing of the subaortic space. The chimney technique could theoretically provide a wide subaortic space.

METHODS

Twenty-nine patients with both pre- and post-NP computed tomography data available of the 37 consecutive patients who underwent NP in our institution were reviewed. Arch height, arch width, sinus of Valsalva diameter, area under the neoaortic arch and arch angle were measured. These patients were divided according to the neo-arch reconstruction technique, chimney reconstruction technique (CR) or conventional direct reconstruction technique (DR).

RESULTS

Median age and weight at NP were 2.1 months and 3.5 kg, respectively. Twenty-two patients underwent previous bilateral PA banding. During NP, 17 CR and 12 DR were performed. Four patients in the DR group developed PA compression. No neoaortic arch dilatation was found in either group. Post-NP arch width, area under the neo-arch and the arch angle were significantly larger in the CR group. Pre-NP arch height was significantly smaller in DR patients with PA compression than in those without.

CONCLUSIONS

The chimney technique decreased the risk of PA compression and provided a wider subaortic space and a less acute arch angle. This technique had no short-term effect on the neoaortic root. Small preoperative arch height is a potential risk factor for PA compression in DR, and the chimney technique could be an effective solution.

High-degree Norwood neoaortic tapering is associated with abnormal flow conduction and elevated flow-mediated energy loss

OBJECTIVE

The Norwood neoaortic arch biomechanical properties are abnormal due to reduced vessel wall compliance and abnormal geometry. Others have previously described neoaortic geometric distortion by the degree of diameter reduction (tapering) and associated this with mismatched ventricular-neoaortic coupling, abnormal flow hemodynamic parameters, and worse patient outcome. Our purposes were to investigate the influence of neoaortic tapering (ie, diameter reduction) on flow-mediated viscous energy loss (E_L') in post-Norwood palliated hypoplastic left heart syndrome patients, and correlate flow-geometry with single ventricle power generation.

METHODS

Twenty-six palliated hypoplastic left heart syndrome patients underwent comprehensive cardiac evaluation with 4-dimensional-flow magnetic resonance imaging. Patients were grouped into high- (group H, n = 13) and low- (group L, n = 13) degree neoaortic tapering using the median cutoff value of neoaortic diameter variance. E_L' was calculated along standardized segments using 4-dimensional-flow magnetic resonance imaging. Flow-mediated power loss as a percentage of total power generated by the single ventricle was determined.

RESULTS

Group H had a higher prevalence of abnormal recirculating flow in the neoaorta and elevated neoaortic E_L' in the ascending aorta (1.0 vs 0.6 mW; P = .004). Group H E_L' was increased across the entire thoracic aorta (2.6 vs 1.3 mW; P = .002) and accounted for 0.7% of generated ventricular power versus 0.3% in group L (P = .024). E_L' directly correlated with the degree of ascending aortic dilation (R = 0.49; P = .012).

CONCLUSIONS

Patients with high degree neoaortic tapering have more perturbed flow through the neoaorta and increased E_L'. Flow-mediated energy loss due to abnormal flow represents irreversibly wasted power generated by the single right ventricle. In patients with high-degree neoaortic tapering, E_L' was more than 2-fold greater than low-degree tapering patients. These data suggest that oversizing the Norwood neoaortic reconstruction should be avoided and that patients with distorted neoaortic geometry may warrant increased surveillance for single-ventricle deterioration.

Long-term results of aortic arch reconstruction with branch pulmonary artery homograft patches

BACKGROUND

Homograft tissue is an important reconstructive material used in the surgical correction of a variety of congenital heart defects. The aim of this study is to evaluate the long-term outcome of pulmonary artery (PA) branch patches used in the reconstruction of the thoracic aorta in children.

METHODS

Retrospective review of 124 consecutive pediatric patients undergoing corrective surgery for their congenital heart defects between 2001 and 2016. Survival, reoperation, and reintervention data were collected, as well as imaging data to assess for presence of recoarctation, dilation, or aneurysm formation in the area of patch reconstruction.

RESULTS

Overall 15-year survival was 83.9% and 15-year freedom from reintervention in the area of patch reconstruction was 89.2%. Rates of mortality (0%), cardiac transplantation (0%), and reoperation (0.8%) attributable to the area of patch reconstruction were low. The frequency of catheter-based intervention in the area of patch reconstruction was 9.7%; such interventions were successful in all but one patient, who ultimately underwent successful surgical aortoplasty.

CONCLUSIONS

Homograft patches harvested from PA branches are an effective reconstructive material used for reconstruction of the aorta in small children. Long-term results show no risk of aneurysm formation and low rates of stenosis formation.

Early outcomes and computational fluid dynamic analyses of chimney reconstruction in the Norwood procedure†

OBJECTIVES

The ideal configuration of a reconstructed aortic arch in the Norwood procedure for hypoplastic left heart syndrome is still a matter of debate. Chimney reconstruction was developed to avoid postoperative complications and turbulent flow in the aortic arch. This study sought to clarify early outcomes of the procedure and verify its haemodynamic advantages using computational fluid dynamics (CFD).

METHODS

Fourteen consecutive patients with hypoplastic left heart syndrome or a variant who underwent chimney reconstruction in the Norwood procedure between January 2013 and March 2018 were enrolled. Median age and body weight at the time of operation were 2.5 months and 4.1 kg, respectively. Thirteen patients (93.9%) had been palliated with previous bilateral pulmonary artery (PA) banding. In addition, patient-specific CFD models of neoarches based on postoperative computed tomograms from 6 patients were created and the flow profiles analysed.

RESULTS

Survival rates at 1, 3 and 5 years were 76.6%, 67.3% and 67.3%, respectively. No patient developed left PA compression by neoaorta, neoaortic dilation or neoaortic insufficiency. Only 2 patients (14.3%) required surgical intervention for recoarctation. Fontan completion was performed on 5 patients. On CFD analysis, all reconstructed aortic arches showed low energy loss (9.16-14.4 mW/m2) and low wall shear stresses.

CONCLUSIONS

Chimney reconstruction was a feasible technique when homografts were not readily available. CFD analyses underscored the fact that this technique produced excellent flow profiles. Larger studies should be conducted to clarify long-term outcomes.

Intervention for arch obstruction after the Norwood procedure: Prevalence, associated factors, and practice variability

OBJECTIVE

Arch obstruction after the Norwood procedure is common and contributes to mortality. We determined the prevalence, associated factors, and practice variability of arch reintervention and assessed whether arch reintervention is associated with mortality.

METHODS

From 2005 to 2017, 593 neonates in the Congenital Heart Surgeons' Society Critical Left Heart Obstruction cohort underwent a Norwood procedure. Median follow-up was 3.7 years. Multivariable parametric models, including a modulated renewal analysis, were performed.

RESULTS

Of the 593 neonates, 146 (25%) underwent 218 reinterventions for arch obstruction after the Norwood procedure: catheter-based (n = 168) or surgical (n = 50) at a median age of 4.3 months (quartile 1-quartile 3, 2.6-5.7). Interdigitation of the distal aortic anastomosis was protective against arch reintervention. Development of ≥ moderate tricuspid valve regurgitation and right ventricular dysfunction at any point was associated with arch reintervention. Nonsignificant variables for arch reintervention included shunt type and preoperative aortic measurements. Surgical arch reintervention was protective against arch reintervention, but transcatheter reintervention was associated with increased reintervention. Arch reintervention was not associated with increased mortality. There was wide institutional variation in incidence of arch reintervention (range, 0-40 reinterventions per 100 years patient follow-up) and in preintervention gradient (range, 0-64 mm Hg).

CONCLUSIONS

Interdigitation of the distal aortic anastomosis during the Norwood procedure decreased the risk of arch reintervention. Surgical arch reintervention is more definitive than transcatheter. Arch reintervention after the Norwood procedure is not associated with increased mortality. Serial surveillance for arch obstruction, integrated with changes in right ventricular function and tricuspid valve regurgitation, is recommended after the Norwood procedure to improve outcomes.

Porcine Small Intestinal Submucosa May Be a Suitable Material for Norwood Arch Reconstruction

BACKGROUND

Norwood palliation typically requires patch augmentation of the ascending aorta and aortic arch. Patients having undergone Norwood palliation are at risk of recurrent arch obstruction, the risk of which may be affected by the type of patch material used at the time of Norwood palliation. We sought to determine the freedom from neoaortic arch reintervention and overall survival in patients who underwent Norwood palliation utilizing porcine small intestinal submucosa (PSIS) as the patch material.

METHODS

Retrospective chart review was performed to identify patients who underwent a Norwood operation utilizing PSIS material at our institution. Cardiac diagnosis, age at surgery, shunt type, need for reintervention, and outcome (survival, transplant, and death) were evaluated.

RESULTS

Forty-four patients had PSIS material utilized for arch reconstruction at the time of Norwood palliation. There were only five neoaortic arch reinterventions in 4 patients (11.4%). An additional 10 reinterventions, unrelated to the PSIS patch, were performed, including five shunt revisions and five branch pulmonary artery interventions. There were 3 deaths, and 5 patients underwent transplantation. Median follow-up was 387.5 days (range, 4 to 1,513).

CONCLUSIONS

Freedom from neoaortic arch reintervention and survival after Norwood palliation with PSIS patch material is promising. The PSIS appears noninferior and may be an appropriate tissue choice for Norwood palliation. Studies with longer follow-up are needed to determine the rate of neoaortic reintervention over time.

Is Decellularized Porcine Small Intestine Sub-mucosa Patch Suitable for Aortic Arch Repair?

Introduction: We reviewed our experience with decellularized porcine small intestine sub-mucosa (DPSIS) patch, recently introduced for congenital heart defects. Materials and Methods: Between 10/2011 and 04/2016 a DPSIS patch was used in 51 patients, median age 1.1 months (5 days to 14.5 years), for aortic arch reconstruction (45/51 = 88.2%) or aortic coarctation repair (6/51 = 11.8%). All medical records were retrospectively reviewed, with primary endpoints interventional procedure (balloon dilatation) or surgery (DPSIS patch replacement) due to patch-related complications. Results: In a median follow-up time of 1.5 ± 1.1 years (0.6-2.3years) in 13/51 patients (25.5%) a re-intervention, percutaneous interventional procedure (5/51 = 9.8%) or re-operation (8/51 = 15.7%) was required because of obstruction in the correspondence of the DPSIS patch used to enlarge the aortic arch/isthmus, with median max velocity flow at Doppler interrogation of 4.0 ± 0.51 m/s. Two patients required surgery after failed interventional cardiology. The mean interval between DPSIS patch implantation and re-intervention (percutaneous procedure or re-operation) was 6 months (1-17 months). While there were 3 hospital deaths (3/51 = 5.9%) not related to the patch implantation, no early or late mortality occurred for the subsequent procedure required for DPSIS patch interventional cardiology or surgery. The median max velocity flow at Doppler interrogation through the aortic arch/isthmus for the patients who did not require interventional procedure or surgery was 1.7 ± 0.57 m/s. Conclusions: High incidence of re-interventions with DPSIS patch for aortic arch and/or coarctation forced us to use alternative materials (homografts and decellularized gluteraldehyde preserved bovine pericardial matrix).

Interstage Home Monitoring After Newborn First-Stage Palliation for Hypoplastic Left Heart Syndrome: Family Education Strategies

Children born with hypoplastic left heart syndrome are at high risk for serious morbidity, growth failure, and mortality during the interstage period, which is the time from discharge home after first-stage hypoplastic left heart syndrome palliation until the second-stage surgical intervention. The single-ventricle circulatory physiology is complex, fragile, and potentially unstable. Multicenter initiatives have been successfully implemented to improve outcomes and optimize growth and survival during the interstage period. A crucial focus of care is the comprehensive family training in the use of home surveillance monitoring of oxygen saturation, enteral intake, weight, and the early recognition of "red flag" symptoms indicating potential cardiopulmonary or nutritional decompensation. Beginning with admission to the intensive care unit of the newborn with hypoplastic left heart syndrome, nurses provide critical care and education to prepare the family for interstage home care. This article presents detailed nursing guidelines for educating families on the home care of their medically fragile infant with single-ventricle circulation.

Glutaraldehyde Treatment of Allografts and Aortic Outcomes Post-Norwood: Challenging Surgical Decision

BACKGROUND

Glutaraldehyde (GA) treatment of allografts used for arch reconstruction prevents the immunologic sensitization that occurs with untreated allografts, but its use may cause tissue changes that predispose to recurrent obstruction. The objective was to determine whether GA treatment of allografts used in Norwood procedures increases the risk of recurrent aortic obstruction.

METHODS

All infants who underwent a Norwood procedure between 2000 and 2015 were included. Cryopreserved pulmonary allografts were used for all arch reconstructions; starting in 2005 all were treated with GA before use. Complete follow-up was obtained, including survival, transplantation, and all repeat procedures. Competing risks analyses were used to assess for differences in aortic reintervention over time.

RESULTS

Two hundred six infants (132 male) were included. There were 60 deaths and 14 transplantations; 5-year transplantation-free survival was 71.9%. GA treatment of patches (n = 142, 68.9%) was not predictive of death (hazard ratio [HR] 1.38, 95% confidence interval [CI]: 0.61 to 3.08). Fifty-five patients had at least one aortic reintervention and 31 patients (15.0%) required surgical aortic reintervention. At 1-year, freedom from all aortic reintervention was similar between patients with and without treated patches, but freedom from surgical aortic reintervention was lower in the treated group (87.6% versus 95.3%, p = 0.0256). GA treatment was not associated with the combined end point of catheter-based or surgical reintervention but was associated with specific need for surgical reintervention (HR 4.05, 95% CI: 1.19 to 13.77).

CONCLUSIONS

GA treatment is associated with increased late surgical aortic reintervention. The advantages of decreased sensitization with GA treatment need to be balanced against the risk of aortic reobstruction.

Evaluation of Residual Coarctation in Infants with a Single Right Ventricle after Stage I Palliation

In infants with a single right ventricle (RV), stage I palliation involves aortic reconstruction, systemic-to-pulmonary shunt placement, and atrial septectomy. Many require re-intervention for residual coarctation of the aorta (CoA). Doppler echocardiography can detect residual CoA in most infants, but its ability to predict severity has not been studied. This study compares gradients from Doppler interrogation to those from cardiac catheterization in infants with residual CoA. We performed a retrospective study of infants after stage I palliation from 2000 to 2014. Infants with an echocardiogram and catheterization before the second-stage palliative surgery were included. Infants with an echocardiogram >30 days before catheterization were excluded. Doppler-derived gradients were compared to catheterization-derived gradients. Echocardiographic assessment of tricuspid valve (TV) and RV function were recorded. The cohort included 95 infants, and thirty-three (35%) had CoA. Doppler-derived and catheterization-derived gradients correlated weakly in infants with CoA (r = 0.37, p = 0.036) and without CoA (r = 0.35, p = 0.005). Among infants with CoA, 17/33 had none or trivial tricuspid regurgitation (TR) and normal RV function, and Doppler-derived gradients correlated with catheterization gradients in this group (r = 0.71, p = 0.001). In 16/33 infants with ≥moderate TR or RV dysfunction, gradients did not correlate (r = -0.003, p = 0.992). After a stage I palliation in infants with single RV and CoA, Doppler-derived gradients poorly predicted the severity of CoA. Infants with normal TV or RV function had Doppler-derived gradients more predictive of catheterization-derived gradients. Doppler-derived gradients have limited utility in determining the severity of CoA after a stage I palliation.

Single-stage repair of Taussig-Bing anomaly and interrupted aortic arch-type A

The surgical repair of Taussig-Bing anomaly and associated lesions has evolved over the years from palliative procedures to complete repairs-either in two stages or in one single stage. We present a video illustrating our preferred surgical option in the treatment of Taussig-Bing anomaly, in this case, with an associated type A interrupted aortic arch.

Selective Use of the Blalock-Taussig Shunt and Right Ventricle-to-Pulmonary Artery Conduit During the Norwood Procedure

Background:

The single ventricle reconstruction trial showed better one-year transplant-free survival for the right ventricle-to-pulmonary artery (RV-to-PA) conduit over the modified Blalock-Taussig shunt (mBTS) at Norwood operation. However, concerns remain about the long-term effects of a neonatal ventriculotomy. In our institution, we have used specific selection criteria for the use of mBTS in the Norwood operation.

Methods:

We reviewed 122 consecutive neonates undergoing the Norwood procedure from December 2006 to December 2013. We used the following criteria to select our source of pulmonary blood flow: (1) presence of a dominant morphologic left ventricle; (2) presence of antegrade blood in an ascending aorta that is greater than 3 mm; and (3) presence of significant large “crossing coronaries” on ventricle. All patients who met any of the above 3 criteria underwent an mBTS while the remaining patients underwent an RV-to-PA conduit.

Results:

Seventy-five (61.5%) patients had the RV-to-PA conduit and 47 (38.5%) patients had an mBTS. The overall surgical mortality was 9%. Mean follow-up interval was 23.5 months. Actuarial transplant-free survival was similar at 12, 24, 36, and 48 months in both the mBTS group and the RV-to-PA conduit group. In the RV-to-PA conduit group, actuarial transplant-free survival was 73% at 12 months, 71% at 24 months, 71% at 36 months, and 67% at 48 months, while in the mBTS group, actuarial transplant-free survival was 82% at 12 months, 75% at 24 months, 75% at 36 months, and 75% at 48 months.

Conclusion:

Our selection criteria for mBTS have allowed us to obtain equivalent transplant-free survival at 12, 24, 36, and 48 months when compared to the RV-to-PA conduit group.

3D-Printed Biodegradable Polymeric Vascular Grafts

Congenital heart defect interventions may benefit from the fabrication of patient-specific vascular grafts because of the wide array of anatomies present in children with cardiovascular defects. 3D printing is used to establish a platform for the production of custom vascular grafts, which are biodegradable, mechanically compatible with vascular tissues, and support neotissue formation and growth.

Hybrid therapy for hypoplastic left heart syndrome: Myth, alternative, or standard?

OBJECTIVE

This retrospective study presents our operative results, mortality, and morbidity with regard to pulmonary artery growth and reinterventions on the pulmonary artery and aortic arch, including key features of our institutional standards for the 3-stage hybrid palliation of patients with hypoplastic left heart syndrome.

METHODS

Between June 1998 and February 2015, 182 patients with hypoplastic left heart structures underwent the Giessen hybrid stage I procedure. Among these, 126 patients with hypoplastic left heart syndrome who received a univentricular palliation or heart transplantation were included in the main analysis. Median age and body weight of patients at hybrid stage I were 6 days (0-237) and 3.2 kg (1.2-7), respectively. Comprehensive stage II operation was performed at 4.5 months (2.9-39.5), and Fontan completion was established at 33.7 months (21.1-108.2). Operative and interstage mortality, morbidity, growth and reinterventions on the pulmonary arteries, and long-term operative results of the aortic arch reconstruction were assessed.

RESULTS

Median follow-up time after Giessen hybrid stage I palliation was 4.6 years (0-16.8). Operative mortality at hybrid stage I, comprehensive stage II, and Fontan completion was 2.5%, 4.9%, and 0%, respectively. Cumulative interstage mortality was 14.2%. At 10 years, the probability of survival is 77.8%. Body weight (<2.5 kg) and aortic atresia had no significant impact on survival. McGoon ratio did not differ at comprehensive stage II and Fontan completion (P = .991). Freedom from pulmonary artery intervention was estimated to be 32.2% at 10 years. Aortic arch reinterventions were needed in 16.7% of patients; 2 reoperations on the aortic arch were necessary.

CONCLUSIONS

In view of the early results and long-term outcome, the hybrid approach has become an alternative to the conventional strategy to treat neonates with hypoplastic left heart syndrome and variants. Further refinements are warranted to decrease patient morbidity.

Ring-reinforced Sano conduit at Norwood stage I reduces proximal conduit obstruction

BACKGROUND

Reinterventions for proximal conduit obstruction or on the pulmonary arteries are frequent after the Sano-modified stage I Norwood palliation of hypoplastic left heart syndrome. We report our initial experience with a modified Sano technique using a ring-reinforced graft inserted transmurally through the right ventricle with a limited ventriculotomy.

METHODS

All patients who underwent the Sano-modified stage I Norwood procedure using a modified "dunked" technique from September 2010 to September 2012 at our institution were reviewed. An historical control group consisted of patients undergoing the traditional Sano right ventricle-to-pulmonary artery conduit anastomosed to the epicardium. The primary outcome measures included death, reintervention on the Sano and pulmonary arteries, and ventricular function.

RESULTS

The study included 29 patients. No patients required intervention on the Sano conduit, pulmonary arteries, or aortic arch before discharge after the stage I procedure. During a median follow-up of 20 months (range, 26 days to 3.3 years), survival was estimated at 96.6% ± 3.4% at 1 month and 86.2% ± 6.4% at the latest follow-up. One patient underwent heart transplantation. No interstage intervention was required on the proximal or distal Sano conduit. Intervention was required on the midportion of the conduit in 1 patient and on the pulmonary arteries in 3 patients. At the time of the bidirectional Glenn anastomosis, freedom from conduit and pulmonary artery intervention was estimated at 92.3% ± 7.4% and 90.1% ± 8.7%, respectively, and global right ventricular dysfunction was mild or less in 84% (16 of 19) of patients.

CONCLUSIONS

The ring-reinforced right ventricle-to-pulmonary artery Sano conduit transmurally inserted into the right ventricle provides acceptable results, with a low incidence of interstage reinterventions in patients undergoing stage I palliation.

Intervention for recoarctation in the single ventricle reconstruction trial: incidence, risk, and outcomes

BACKGROUND

Recoarctation after the Norwood procedure increases risk for mortality. The Single Ventricle Reconstruction (SVR) trial randomized subjects with a single right ventricle undergoing a Norwood procedure to a modified Blalock-Taussig shunt or a right ventricle-pulmonary artery shunt. We sought to determine the incidence of recoarctation, risk factors, and outcomes in the SVR trial.

METHODS AND RESULTS

Recoarctation was defined by intervention, either catheter based or surgical. Univariate analysis and multivariable Cox proportional hazard models were performed with adjustment for center. Of the 549 SVR subjects, 97 (18%) underwent 131 interventions (92 balloon aortoplasty, 39 surgical) for recoarctation at a median age of 4.9 months (range, 1.1-10.5 months). Intervention typically occurred at pre-stage II catheterization (n=71, 54%) or at stage II surgery (n=38, 29%). In multivariable analysis, recoarctation was associated with the shunt type in place at the end of the Norwood procedure (hazard ratio, 2.0 for right ventricle-pulmonary artery shunt versus modified Blalock-Taussig shunt; P=0.02), and Norwood discharge peak echo-Doppler arch gradient (hazard ratio, 1.07 per 1 mm Hg; P<0.01). Subjects with recoarctation demonstrated comorbidities at pre-stage II evaluation, including higher pulmonary arterial pressures (15.4±3.0 versus 14.5±3.5 mm Hg; P=0.05), higher pulmonary vascular resistance (2.6±1.6 versus 2.0±1.0 Wood units·m(2); P=0.04), and increased echocardiographic volumes (end-diastolic volume, 126±39 versus 112±33 mL/BSA(1.3), where BSA is body surface area; P=0.02). There was no difference in 12-month postrandomization transplantation-free survival between those with and without recoarctation (P=0.14).

CONCLUSIONS

Recoarctation is common after Norwood and contributes to pre-stage II comorbidities. Although with intervention there is no associated increase in 1-year transplantation/mortality, further evaluation is warranted to evaluate the effects of associated morbidities.

Recoarctation after the norwood I procedure for hypoplastic left heart syndrome: incidence, risk factors, and treatment options

BACKGROUND

Early survival after the Norwood I procedure has improved over the years, but subsequent morbidity is not yet well assessed. The aim of this study was to review the incidence of recoarctation, evaluate risk factors, and analyze treatment options.

METHODS

We reviewed the medical records of 124 consecutive patients with hypoplastic left heart syndrome (HLHS) who underwent the Norwood I procedure. Reconstruction of the aortic arch was performed in a standardized manner, removing all visible ductal tissue and enlarging the distal anastomosis with a Y incision into the descending aorta. Angiographic assessment with measurement of the peak gradient across the aortic arch was performed before the second stage was performed.

RESULTS

Recoarctation of the aorta was documented in 13 patients (13.4%) at a mean time of 6.4 ± 5 months after the Norwood procedure. One patient died before the recoarctation could be treated. Right ventricular function was good in all except 1 patient at the time of diagnosis. Ten patients underwent 16 percutaneous balloon angioplasties, and 2 patients underwent operative enlargement of the neoaorta. The pretreatment peak gradient of 24.1 ± 16 mm Hg (10-64 mm Hg) across the aortic arch was significantly reduced to 6.3 ± 4 mm Hg (0-14 mm Hg) after angioplasty or operation (p = 0.003). There were no procedure-related deaths. No risk factor for recoarctation could be identified.

CONCLUSIONS

A standardized surgical technique for reconstruction of the aorta leads to a low recoarctation rate. Balloon angioplasty can be performed in the majority of patients before the second-stage procedure.