Shunt right or left? Decision 2016
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Norwood procedure
Pulmonary artery banding
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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Objective Norwood and hybrid procedure are two options available for initial palliation of patients with hypoplastic left heart syndrome (HLHS). Our study aimed to assess potential differences in right ventricular (RV) function and pulmonary artery dimensions using cardiac magnetic resonance (CMR) in survivors with HLHS. Methods 42 Norwood (mean age 2.4±0.8) and 44 hybrid (mean age 2.0±1.0 years) patients were evaluated by CMR after stage II palliation prior to planned Fontan completion. Initial stage I Norwood procedure was performed using a modified Blalock-Taussig shunt, while the hybrid procedure consisted of bilateral pulmonary artery banding and arterial duct stenting. Need for reinterventions and subsequent outcomes were also assessed. Results Norwood patients had larger RV end-diastolic dimensions (91±23 vs 80±31 mL/m 2 , p=0.004) and lower heart rate (90±15 vs 102±13, p<0.001) than hybrid patients. Both Norwood and hybrid patients showed preserved global RV pump function (59±9 vs 59%±10%, p=0.91), while RV strain, strain rate and intraventricular synchrony were superior in the Norwood group. Pulmonary artery size was reduced (lower lobe index 135±74 vs 161±62 mm 2 /m 2 , p=0.02), and reintervention rate was significantly higher in the hybrid group whereas subsequent outcome did not differ significantly (p=0.24). Conclusions Norwood and hybrid strategy were associated with equivalent and preserved global RV pump function while development of the pulmonary arteries and reintervention rate were superior using the Norwood approach. Impaired RV myocardial deformation as a potential marker of early RV dysfunction in the hybrid group may have a negative long-term impact in this population.
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Although Norwood-type operation is a fundamental procedure for hypoplastic left heart syndrome and its variants, the surgical risk is still high even in the high volume center. Bilateral pulmonary artery (PA) banding( BPAB) is an alternative procedure to avoid the risk in the neonatal period. We clarified the impacts of BPAB on the surgical and long-term outcomes in HLHS and its variants. Consecutive 85 patients( classical HLHS:52, variant:33) who underwent surgical intervention between July, 1993 and December, 2012 were evaluated. Fetal diagnosis was done in 37 patients (44%). Forty-two patients underwent primary Norwood operation[ Gp N, Blalock-Taussig( BT):29, right-ventricle( RV)-PA conduit:13] and the remaining 43 patients underwent BPAB followed by Norwood operation. Among them, 4 patients did not reach Norwood [9%, atrioventricular valve regurgitation (AVVR):1, infection:1, preoperative shock:2). The survived 39 patients were divided into 2 groups;Gp BN (BPAB → Norwood+BT/RV-PA conduit, n=22), Gp BG [BPAB → Norwood+bidirectional Glenn procedure(BDG), n=17]. BPAB for HLHS and its variants is useful in terms of lower mortality. The 2nd stage palliation is so important that modified Norwood procedure with BT shunt or RV-PA conduit contribute to the lower morbidity including neurological outcome. Norwood+BDG strategy might be beneficial for the high risk patients such as with poor cardiac function or low body weight.
Norwood procedure
Pulmonary artery banding
Atrioventricular valve
Fontan Procedure
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To investigate the early and long-term outcomes of the deferred Norwood procedure by bilateral pulmonary artery banding (BPAB) versus the neonatal Norwood procedure.
Norwood procedure
Fontan Procedure
Interquartile range
Pulmonary artery banding
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Background: Infants w/ high risk hypoplastic left heart syndrome and variants (HR-HLHS) due to low birth weight or gestational age experience worse outcomes. Optimal management remains unknown. We sought to 1. compare primary Norwood to hybrid strategies in HR-HLHS 2. identify predictors of futility. Hypothesis: Primary Norwood offers improved outcomes compared to hybrid strategies. Very low birth weight and other anomalies may represent futility. Methods: We reviewed HR-HLHS from the National Pediatric Cardiology Quality Improvement Collaborative database. Patients with birth weight <2.5kg or gestation <35 weeks, and age ≤ 30 days at admission were included (N=398). Norwood (n=225), hybrid (pulmonary artery band (PAB) + ductal stent, n=76), and PAB w/ prostaglandin (PAB/PGE, n=77) were compared. Transplantation referral (n=1) and comfort care (n=19) occurred. Baseline factors, 1-year survival, and stage 2 completion were reviewed. Results: Table shows baseline HR-HLHS features. Norwood had higher risk adjusted 1-year survival and stage 2 completion than hybrid strategies, including in < 2.1 kg (Figure). On multivariable analysis, hybrid (HR 2.8), genetic abnormality (HR 1.5), and ECMO (HR: 7.2) were significantly associated w/ decreased 1-year survival and stage 2 completion, while higher birth weight (HR: 1.5) was associated w/ increased stage 2 completion. Less than 25% of HR-HLHS w/ birthweight < 2.1 kg and ≥ 1 genetic abnormality was alive with stage 2 at the end of follow-up. Conclusions: HR-HLHS have better outcomes following primary Norwood than hybrid palliation. In patients w/ birth weight < 2.1 kg and genetic abnormalities, hybrid or Norwood may be futile.
Norwood procedure
Pulmonary artery banding
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Objectives: We report our experience with initial bilateral pulmonary artery banding (PAB) and postponing the Norwood procedure (NP) for high risk neonates.
Pulmonary artery banding
Norwood procedure
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Norwood procedure
Pulmonary artery banding
Great vessels
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Norwood procedure
Pulmonary artery banding
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To compare the haemodynamics and perioperative course of initial palliation with bilateral pulmonary artery banding (PAB) and the Norwood procedure.Between April 2004 and December 2007, 43 consecutive children with hypoplastic left heart syndrome (HLHS) or a variant underwent initial palliation (PAB, n=18; Norwood, n=25). Clinical perioperative data were analysed. In the PAB group, lipo-prostaglandin E1 administration was continued with hospitalisation until stage 2 palliation with a bi-directional Glenn shunt and the Norwood procedure.There were no significant differences in the age and operative weight of patients who received stage 1 palliation (PAB, 12+/-9 days, 2.7+/-0.6 kg; Norwood, 12+/-8 days, 2.8+/-0.4 kg). The PAB group had more high-risk patients than the Norwood group (PAB, 83%; Norwood, 48%, p=0.04). Increased early and inter-stage mortality were observed in patients who underwent the Norwood procedure (early mortality with PAB, 6% vs Norwood, 12%; inter-stage mortality, 6% vs 27%, respectively). Mortality between stages 1 and 2 was 11% for the PAB group and 36% for the Norwood group. The Kaplan-Meier survival estimate at 1 year did not differ between groups (77% for the PAB group, 64% for the Norwood group). Ductal stenosis was found in one patient in the PAB group during the follow-up period. Twenty-eight patients underwent stage 2 reconstruction, and the patients in the PAB group were younger at the time of surgery (PAB, 116 days; Norwood, 224 days). There were no significant differences between groups in pulmonary artery index regarding body surface area (BSA) (PAB, 179 mm(2)BSA(-1); Norwood, 194 mm(2)BSA(-1)) and the incidence of ventricular dysfunction after stage 2 construction (PAB, 21%; Norwood, 21%).Bilateral PAB with continuous lipo-prostaglandin E1 administration may improve early and intermediate mortality in infants with HLHS. Intimate care with hospitalisation may contribute to the results.
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Norwood procedure
Pulmonary artery banding
Vascular surgery
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