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J Thorac Cardiovasc Surg 2003;126:1268-1270
© 2003 The American Association for Thoracic Surgery
Editorials |
a Department of Cardiothoracic Surgery, Children's Hospital Medical Center, Cincinnati, Ohio, USA
Received for publication February 12, 2003; accepted for publication March 4, 2003.
* Address for reprints: Jeffrey M. Pearl, MD, the Department of Surgery, Children's Hospital Medical Center, 3333 Burnet Ave, OSB-3, Cincinnati, OH 45229, USA
pearj0@chmcc.org
| The first 20% of the full text of this article appears below. |
| See related article on page 1378.
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The Norwood procedure has undergone numerous modifications since its original description.1 The term "modified" Norwood now applies to several variations both in the reconstructive techniques and in the conduct of bypass.2,3 Surgeons now have available technical modifications that can be applied to the variable anatomy encountered within the complex spectrum of hypoplastic left heart syndrome. Of equal importance to the technical advances, better understanding of the Norwood physiology and improved postoperative management have resulted in improved outcomes.4-6 In fact, it is difficult to separate the technical aspects from the physiologic as, more than in any other lesion, the two are interdependent.
Perhaps one of the most critical observations made regarding post-Norwood physiology was the concept of pulmonary over-circulation and balancing the systemic/pulmonary flow (Qp/Qs) ratio.5,7 Initial surgical response to increased understanding of this phenomenon included the use of smaller shunts, with a 3.5-mm shunt being used for most infants and even a 3.0-mm shunt for those weighing less than 3.0 kg.8 Despite a more favorable Qp/Qs ratio with the use of smaller shunts, the fact that the shunt in a typical Norwood procedure comes off a systemic vessel unavoidably results in diastolic runoff and lower diastolic pressure. In addition, using a "one size fits all" approach can result in significant variation in saturations and hemodynamics because of other variables such as size of the patient, size of the feeding vessel, overall cardiac output, and pulmonary vascular resistance. Hence, inadequate systemic perfusion as a result of increased Qp/Qs and significant cyanosis related to a decreased Qp/Qs are not uncommon in the early postoperative period. The management of these patients can be
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