Diagnosis and catheter treatment of innominate artery stenosis following stage I Norwood procedure
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Abstract:
Four infants aged 20-115 days (mean, 57.8 days) who had undergone stage I Norwood procedure for hypoplastic left heart syndrome came to early cardiac catheterization (6-112; mean, 47.3 days) following surgery because of significant arterial desaturation (pulse oximetry indicating oxygen saturations consistently in the 40%-70% range). Cardiac catheterization demonstrated a significant systolic pressure gradient between the ascending aorta and innominate artery (30-65; mean, 51 mm Hg) as the likely cause of diminished pulmonary blood flow in these patients. Routine angiography by itself was not conclusive in identifying a discrete area of obstruction, but selective angiography coupled with a knowledge of the obstruction did reveal the stenosis. All patients were successfully treated with balloon dilatation of the stenotic area, with the pressure gradient being reduced to 7-25 (mean, 17 mm Hg) immediately following dilatation. On follow-up catheterization in three patients, the systolic gradients were 3, 6, and 9 mm Hg. Arterial oxygen saturations rose from 63.5% predilatation to 77.3% immediately postdilatation and 81% on follow-up evaluation. In conclusion, innominate artery stenosis is an important cause of diminished blood flow through a modified right Blalock-Taussig shunt. Routine angiography will often miss the diagnosis. Pressure gradients and selective angiograms are necessary in order to make the diagnosis, although careful noninvasive assessment should also be diagnostic of this problem. Catheter dilatation is therapeutic in this situation and can be performed early after surgery in the absence of a fresh suture line.Keywords:
Cardiac catheterization
Norwood procedure
Arterial catheter
Norwood procedure
Single Center
Cardiac catheterization
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Norwood procedure
Vascular surgery
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Norwood procedure is the most common surgical treatment strategy for hypoplastic left heart syndrome (HLHS) (1). Although advances in surgical techniques and postoperative care have significantly improved the survival rates after Norwood, a significant proportion of children develop heart failure (HF) at different stages of palliation (1,2).
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Limited data on performing bilateral pulmonary artery banding (BPAB) before stage 1 Norwood procedure suggest that some patients may benefit through the postponement of the major cardiopulmonary bypass procedure. The objective of this study was to evaluate the effectiveness of BPAB in the surgical management of high-risk patients with hypoplastic left heart syndrome (HLHS).
Norwood procedure
Pulmonary artery banding
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Norwood procedure
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Cardiothoracic surgery
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The optimal approach to hypoplastic left heart syndrome (HLHS) is controversial. The palliative Norwood operation, cardiac transplantation, and no surgical intervention have all been advocated. Centers that perform the Norwood operation have met with varied results, and conflicting reports exist regarding factors predictive of stage I outcome. From January 1990 to January 1996, 67 patients with HLHS were admitted with intent to perform the staged Norwood procedure. Fourteen patients did not undergo surgery. In the 53 patients treated surgically, outcome was reviewed, and 10 potential risk factors for first stage mortality were analyzed. Forty-one infants survived the Norwood I operation to hospital discharge (77% of the surgically treated patients and 61% of the entire group, including those who did not undergo operation) with 6 additional deaths 3 to 5 months after operation. Univariate analysis showed cardiopulmonary bypass time and circulatory arrest time to be significant risk factors for hospital mortality. Multivariate analysis revealed only cardiopulmonary bypass time as significant (p <0.01). Of the 15 prenatally diagnosed newborns who underwent surgery, 11 survived (p = 0.72). Ten of 11 patients with preoperative organ damage survived (p = 0.42). Among the 35 bidirectional Glenn (Norwood II) and Fontan (Norwood III) procedures performed, there were 2 deaths. The 5-year actuarial survival for patients who underwent operations was 61%. The Norwood procedure is a favorable option for the infant with HLHS. Surgical survival may be affected by a prolonged cardiopulmonary bypass time, but is not affected by other factors analyzed, including prenatal diagnosis and preoperative organ damage.
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Aims: Bilateral pulmonary banding plus Ductus stenting (Hybrid) and consecutive combined Norwood and Glenn operation at the age of four month has evolved as standard procedure for hypoplastic left heart syndrome (HLHS) in some institution. With excellent results for Norwood procedure (Norwood) and almost no mortality, we reserved Hybrid for those with contraindications for Norwood.
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Background: The Norwood procedure is often performed to treat hypoplastic left heart syndrome (HLHS). Only Blalock-Taussig (BT) shunt is used with the Norwood procedure in our institute. Objective: To analyze the first-stage palliation for HLHS. Patients and methods: The Norwood procedure with right modified BT shunt was performed in 26 patients with HLHS between August 1996 and November 2008. The first four patients were performed using only autologous great vessel tissue (group 1), and the other 22 patients were operated with the Norwood procedure using a homograft for arch reconstruction (group 2). Results: The hospital mortality was 50.0 % in group 1 and 18.2% in group 2. The overall hospital mortality was 23.1%. Four out of twenty survivors (20%) had the modified Fontan procedure. Conclusion: Only a limited number of pediatric cardiac centers offered surgical treatment of the hypoplastic left heart syndrome. The survival rate in our study was in acceptable range despite the limited resource.
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Objectives: The development of a re-coarctation after the Norwood I procedure is a known complication in patients with hypoplastic left heart syndrome (HLHS).
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