HOW I DO IT ? MODIFIED NORWOOD’S OPERATION

1. HOW I DO IT ?MODIFIED NORWOOD’S OPERATION VICHAI BENJACHOLAMAS, MD. CHULALONGKORN HOSPITAL

2. 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

3. HYPOPLASTIC LEFT HEART SYNDROME

4. HYPOPLASTIC LEFT HEART SYNDROME • Perop. Management • PGE-1  open PDA • Avoid oxygen • Correct acidosis • Inotrope • Diuretic • Intubation if neccessary

5. HYPOPLASTIC LEFT HEART SYNDROME Hybrid procedure VS Modified Norwood’s operation

6. HYPOPLASTIC LEFT HEART SYNDROME Hybrid procedure • PDA stenting • Bilateral PA banding • +/- balloon atrial septostomy

7. 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

8. HYPOPLASTIC LEFT HEART SYNDROME • Timing for Norwood’s operation AGE < = 10 days

9. MATERIALS AND METHODS August 1996- November 2008 Modified Norwood’s Operation was performed in 26 neonates

10. MATERIALS AND METHODS AGE 3 - 75 days ( median 11 days )

11. MATERIALS AND METHODS WEIGHT 2,000 - 4,200 grams ( median 2,850 grams )

12. MATERIALS AND METHODS ASCENDING AORTA DIAMETER 2 - 7 mm. ( median 2.5 mm. )

13. HOW I DO IT ?

14. 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

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

20. SURGICAL TECHNIQUE Arch reconstruction with native MPA = 4 patients Homograft = 22 patients aortic = 3/22 patients pulmonic = 19/22 patients

22. SURGICAL TECHNIQUE BT Shunt size selection 3.5 mm. for Body weight <= 3.5 kg. 4.0 mm. for Body weight > 3.5 kg.

23. 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.)

24. SURGICAL TECHNIQUE BT shunt VS Sano shunt

25. SURGICAL TECHNIQUE Advantages/disadvantages of the modified Blalock-Taussig shunt

26. SURGICAL TECHNIQUE Advantages/disadvantages of the Sano shunt

27. SURGICAL TECHNIQUE Sano shunt benefit in AA, MA

28. POSTOPERATIVE CARE RULE OF FOURTY (40) - Fi O2 ~ 0.40 - Pa CO 2 ~ 40 mmHg. - Pa O2 ~ 40 mmHg. - Hct. ~ 40 %

29. POSTOPERATIVE CARE Oxygen saturation after extubation 78 - 85 % ( average 82 % )

30. RESULTS Hospital mortality was 23.1%(6/26) (within 30 days) DOT 3/6 Survival rate = 76.9 % (20/26)

31. 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)

32. LATE RESULTS

33. 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

34. 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 %

35. 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

36. 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.