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J Thorac Cardiovasc Surg 1999;117:920-930
© 1999 Mosby, Inc.
SURGERY FOR CONGENITAL HEART DISEASE |
From the Heart Unit, Birmingham Children's Hospital, Birmingham, United Kingdom.
Read at the Seventy-eighth Annual Meeting of The American Association for Thoracic Surgery, Boston, Mass, May 3-6, 1998.
Received for publication May 8, 1998. Revisions requested June 10, 1998. Revisions received Dec 22, 1998. Accepted for publication Jan 25, 1998. Address for reprints: William J. Brawn, FRCS, Heart Unit, Birmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, United Kingdom.
Background: Classic first-stage Norwood repair of hypoplastic left heart syndrome uses a homograft patch enlargement to obtain an unobstructed aorta and coronary arteries. Because of possible disadvantages of the homograft, such as lack of growth, degeneration and calcification, and availability, we have tried to repair the aorta without patch supplementation.
Methods: Between February 1993 and September 1997, 120 patients, aged birth to 47 days (median 4 days) and weighing 1.7 to 4.4 kg (median 3.1 kg), underwent first-stage palliation for hypoplastic left heart syndrome. The diameter of the ascending aorta ranged from 1.5 to 8.0 mm (median 3.0 mm). Eight patients had an aberrant right subclavian artery arising from the descending thoracic aorta. In 95 patients (group I), all duct tissue was excised and the descending aorta was anastomosed to the aortic arch, which had been opened back into the ascending aorta. Then to this confluence was anastomosed the proximal main pulmonary artery. In the remaining 25 patients (group II), continuity of the aortic arch was maintained and the repair was performed with a Damus-Kaye-Stansel anastomosis. The size of the systemic-to-pulmonary shunt was 3 mm in 48 patients, 3.5 mm in 70, and 4.0 mm in 2.
Results: Circulatory arrest time ranged from 19 to 105 minutes (median 54 minutes). A homograft patch was necessary for the arch reconstruction in 18 patients (15%); 9 group I patients (10%) and 9 group II (36%) (P = .001). There were 82 hospital survivors (68%); 69 group I patients (73%) and 13 group II (52%) (P = .04), 71 patients without a patch (70%) and 11 with a patch (61%) (P > .2). By multiple logistic regression, the aberrant right subclavian artery was a significant risk factor for hospital death (P = .008). There were 6 late deaths. Sixteen of 71 patients (23%) who underwent second-stage palliation had a neoaortic arch obstruction develop, with a peak gradient greater than 10 mm Hg; 14 group I patients (23%) and 2 group II (22%) ( P > .2), 15 without a patch (23%) and 1 with a patch (17%) (P > .2). Overall survivals were 57% at 1 year and 55% at 2 years.
Conclusion: The modified Norwood procedure for first-stage palliation of hypoplastic left heart syndrome is possible in the majority of patients without the use of exogenous materials and does not result in an increased incidence of neoaortic arch obstruction. Repair of the aorta without patch supplementation may improve the potential for long-term growth of the new aorta.
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