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J Thorac Cardiovasc Surg 2003;126:1257-1258
© 2003 The American Association for Thoracic Surgery

Editorials

Pre–stage II mortality after the Norwood operation: Addressing the next challenge

^a Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga, USA

Received for publication March 25, 2003; accepted for publication April 11, 2003.

^* Address for reprints: Joseph M. Forbess, MD, Cardiothoracic Surgery, The Emory Clinic, 1365 Clifton Rd, Suite A2100, Atlanta, GA 30322, USA.

The first 20% of the full text of this article appears below.

See related article on page 1367.

 

Achieving consistently good operative survival after the Norwood operation can be considered an "acid test" of sorts for a pediatric cardiovascular care program. All the provider components of the program are put to the test. Before the operation, these patients must be managed in the intensive care unit with careful management of the balance between systemic and pulmonary blood flow. Patients in whom ductal closure has precipitated near or bona fide circulatory collapse require skillful resuscitation. During the operation, skill and precision are required of surgeon, anesthesiologist, and perfusionist. Volumes have been written about the postoperative challenges presented in the intensive care unit by these neonatal patients, who have been subjected to cardiopulmonary bypass, myocardial ischemia, and, in some cases, whole-body ischemia. Importantly, they emerge from this operation without a repair. This is a single-ventricle circulation, dependent on a systemic-pulmonary shunt for pulmonary blood flow. Maintaining an appropriate balance between systemic perfusion and pulmonary blood flow can again prove difficult. Obtaining adequate cardiac output from the postischemic single ventricle with a coronary circulation that is subjected to continuous diastolic runoff into the lungs through the modified Blalock-Taussig shunt may also be a challenge. It is therefore not surprising that an institutional surgical mortality for the Norwood operation of 10% to 20%, an order of magnitude higher than that seen for many complex neonatal biventricular repairs, can still be considered a fine achievement.

The number of institutions reaching this level of excellence is steadily increasing. In this issue, Ghanayem and colleagues¹ present additional data from the ongoing . . . [Full Text of this Article]