Asian Cardiovasc Thorac Ann 2004;12:372-373
© 2004 Asia Publishing EXchange Ltd
Simplified Antegrade Cerebral Perfusion and Myocardial Protection during Stage I Norwood Procedure
Luca A Vricella, MD,
Piya Samankatiwat, MD,
Marc R de Leval, MD,
Victor T Tsang, MD,
Pascal R Vouhé, MD1
Cardiothoracic Unit, Great Ormond Street Hospital for Children, London, United Kingdom
1 Groupe Hospitalier Necker-Enfants Malades, Service de Chirurgie Cardiaque Pediatrique, Paris, France
For reprint information contact: Victor Tsang, MD Tel: 44 20 7813 8159 Fax: 44 20 7430 1281 Email: tsangv{at}gosh.nhs.uk Cardiothoracic Unit, Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London WC1N 3JH, United Kingdom.
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ABSTRACT
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Several important modifications have been introduced in the intraoperative management of neonates with hypoplastic left heart syndrome during first-stage palliation. Among these, utilization of selective antegrade cerebral perfusion and interposition of a conduit between the right ventricle and pulmonary artery are currently favored by many centers. We briefly describe our current approach to the modified stage I Norwood procedure.
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INTRODUCTION
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Earlier in our experience with the classical Norwood procedure, the arterial cannula was inserted directly into a polytetrafluoroethylene (PTFE) conduit anastomosed to the proximal innominate artery prior to going on cardiopulmonary bypass. The same conduit was then used as an interposition shunt at the end of the procedure after cannulation of the neo-aorta. When we first utilized the Sano modification of the Norwood stage 1 procedure, we continued to perfuse the aortic arch through a small PTFE graft, which was over-sewn at the end of the procedure. The cardiac surgery unit at the Necker Hospital for Sick Children, Paris, has already introduced the technique of direct cannulation of the innominate artery using a small coronary perfusion catheter. We describe herewith our current approach of cannulation and our strategy of cerebral and myocardial perfusion and protection.
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TECHNIQUE
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The arterial inflow line is constructed as a "Y", with one cannula inserted into the ductus arteriosus for systemic perfusion. We have recently utilized a 2 mm direct coronary perfusion cannula (DLP, Grand Rapids, Michigan, USA), inserted through a 6–0 polypropylene purse-string placed at the base of the innominate artery (Figure 1
). Clamps are placed on the descending aorta and between innominate and left common carotid arteries. This allows concomitant antegrade myocardial and cerebral perfusion during reconstruction of the isthmus and distal aortic arch. During periods of selective antegrade cerebral perfusion (SACP) we have routinely achieved (with this particular cannula) flows of up to 30 mL•Kg–1•min–1 at 15°C core temperature, avoiding hypothermic circulatory arrest for aortic arch reconstruction. Cardioplegic cardiac arrest is briefly limited to the time required to perform the most proximal portion of the aortoplasty and for creation of an unrestrictive interatrial communication. Cold blood cardioplegia is delivered directly and reliably into the severely hypoplastic ascending aorta with a second 2 mm perfusion cannula at the time of proximal aortoplasty (Figure 2).
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Figure 1. Schematic illustration of cannulation technique for first-stage palliation of hypoplastic left heart syndrome. The innominate artery is cannulated directly with a 2 mm coronary perfusion catheter. Aortic perfusion is accomplished by direct cannulation of the snared ductus arteriosus (Thick arrowhead).
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Figure 2. Selective antegrade cerebral perfusion is continued while the aortic root is reconstructed; cardiac arrest is induced by intra-aortic cardioplegic infusion with a separate 2 mm cannula. (Thick arrowhead = vascular snare/occlusion)
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DISCUSSION
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Several centers have adopted selective cerebral perfusion techniques to minimize the use of hypothermic circulatory arrest in neonates with hypoplastic left heart syndrome (HLHS) and other complex malformations requiring aortic arch reconstruction as part of either staged palliation or definitive repair.1,3,4 In these reports, cannulation of the innominate artery was typically performed through a PTFE graft, sutured in an end-to-side fashion to the vessel. Perfusion to the descending aorta was provided by a second arterial cannula inserted through the pericardium, just above the left hemi-diaphragm. With this technique, the proximal aspect of the PTFE conduit can be diverted onto the right pulmonary artery at completion of the procedure; the conduit can be alternatively amputated or excised, if pulmonary perfusion is to be obtained with construction of a conduit between right ventricle and pulmonary artery.2,3 Other reports have simplified this approach by direct cannulation of the innominate artery with a 6 or 8 mm arterial cannula,5 which may nevertheless be obstructive within the vasculature of the very small neonate. We currently utilize a right ventricle-to-pulmonary artery conduit strategy rather than reconstruction with a systemic-to-pulmonary shunt. In our experience, satisfactory cerebral perfusion can be provided by direct cannulation of the innominate artery with a 2 mm coronary infusion catheter. Furthermore, infra-diaphragmatic perfusion during SACP has been reported.6 We have adopted profound hypothermia as additional protection to the abdominal viscera. The effectiveness of this technique to provide adequate cerebral perfusion has been evaluated by the senior author, Pascal Vouhé, using near infrared spectroscopy (personal communication). In addition, avoidance of the more time-consuming PTFE graft-to-innominate artery anastomosis and the possibility of repairing what is often already a small vessel is intuitively advantageous.
We have found this minor and easily reproducible modification to reduce cross-clamp time, simplify the procedure and provide reliable cerebral perfusion and cardioplegia delivery.
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REFERENCES
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- Masuda Z, Ishino K, Kato G, Ito A, Asai T, Kuriyama M, et al. Isolated cerebral and myocardial perfusion during aortic arch repair in neonates. J Cardiol
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- Sano S, Ishino K, Kawada M, Arai S, Kasahara S, Asai T, et al. Right ventricle-pulmonary artery shunt in first-stage palliation of hypoplastic left heart syndrome. J Thorac Cardiovasc Surg
2003;126:504–10.[Abstract/Free Full Text]
- Sano S, Kawada M, Yoshida H, Kino K, Irie H, Aoki A, et al. Norwood procedure to hypoplastic left heart syndrome. Jpn J Thorac Cardiovasc Surg
1998;46:1311–6.[Medline]
- Imoto Y, Kado H, Shiokawa Y, Minami K, Yasui H. Experience with the Norwood procedure without circulatory arrest. J Thorac Cardiovasc Surg
2001;122:879–82.[Abstract/Free Full Text]
- Vricella LA, Black MD. Aortic arch reconstruction in neonates without hypothermic circulatory arrest. J Thorac Cardiovasc Surg
2002;123:1221–2.[Free Full Text]
- Pigula FA, Gandhi SK, Siewers RD, Davis PJ, Webber SA, Nemoto EM. Regional low-flow perfusion provides somatic circulatory support during neonatal aortic arch surgery. Ann Thorac Surg
2001;72:401–6.[Abstract/Free Full Text]
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