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J Thorac Cardiovasc Surg 2003;126:504-510
© 2003 The American Association for Thoracic Surgery
Surgery for congenital heart disease |
a Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine and Dentistry, Okayama, Japan
b Department of Anesthesiology, Okayama University Graduate School of Medicine and Dentistry, Okayama, Japan
c Department of Pediatrics,c Okayama University Graduate School of Medicine and Dentistry, Okayama, Japan
Read at the Eighty-second Annual Meeting of The American Association for Thoracic Surgery, Washington, DC, May 5-8, 2002.
Received for publication June 5, 2002; revisions received September 5, 2002; revisions received November 7, 2002; accepted for publication December 2, 2002.
* Address for reprints: Shunji Sano, MD, Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine and Dentistry, 2-5-1 Shikata-cho, Okayama-City 700-8558, Japan
s_sano{at}cc.okayama-u.ac.jp
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Abstract |
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METHODS: Between February 1998 and February 2002, 19 consecutive infants, aged 6 to 57 days (median, 9 days) and weighing 1.6 to 3.9 kg (median, 3.0 kg), underwent a modified Norwood operation with the right ventricle–pulmonary artery shunt. The procedure included aortic reconstruction by direct anastomosis of the proximal main pulmonary artery and a nonvalved polytetrafluoroethylene shunt between a small right ventriculotomy and a distal stump of the main pulmonary artery. The size of the shunt used was 4 mm in 5 patients and 5 mm in 14.
RESULTS: All patients were managed without any particular manipulation to control pulmonary vascular resistance. There were 17 survivors (89%), including 3 patients weighing less than 2 kg. Two late deaths occurred due to obstruction of the right ventricle–pulmonary artery shunt. Thirteen patients underwent a stage II Glenn procedure after a mean interval of 6 months, with 2 hospital deaths. To date, a stage III Fontan procedure has been completed in 4 patients. Overall survival was 62% (13/19). Right ventricular fractional shortening at the last follow-up (3-48 months after stage I) ranged from 26% to 43% (n = 13, mean, 33%).
CONCLUSION: Without delicate postoperative management to control pulmonary vascular resistance, the modified Norwood procedure using the right ventricle–pulmonary shunt provides a stable systemic circulation as well as adequate pulmonary blood flow. This novel operation may be particularly beneficial to low-birth-weight infants with hypoplastic left heart syndrome.
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Survival of infants born with hypoplastic left heart syndrome (HLHS) has steadily improved since Norwood and colleagues1 first reported a multistaged reconstructive approach in 1983. The Norwood procedure (stage I palliation) consists of atrial septectomy, reconstruction of the ascending aorta and aortic arch, and placement of a systemic-pulmonary shunt. Despite successful reconstructive surgery, most deaths occur in the first 24 to 48 hours after surgery due to hemodynamic instability secondary to the unpredictable rapid fall in pulmonary vascular resistance.2,3 Over the past decade, efforts to achieve a balanced circulation during the early postoperative period have focused on limiting pulmonary blood flow and improving systemic blood flow. These measures have included reduction in the size of the systemic-pulmonary shunts,3,4 ventilator manipulations according to delicate blood gas analyses,3,5 use of hypoxic admixtures,6,7 and systemic vasodilators.3,6,8 Although several experienced centers have achieved operative survival for the Norwood procedure between 63% and 94%,3-5,9-11 this procedure still remains a challenging step with high mortality for many institutions with a smaller surgical volume.12,13
To avoid hemodynamic instability associated with the systemic-pulmonary shunt, we constructed a nonvalved polytetrafluoroethylene (PTFE) shunt between the right ventricle and the pulmonary artery (RV-PA shunt) in first-stage palliation of HLHS. In this article we describe our entire experience with the RV-PA shunt, developing surgical techniques, and early- to medium-term results of this novel surgical approach.
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Patients and methods |
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Age at operation ranged from 6 to 57 days (mean, 15 days; median, 9 days). Weight at operation ranged from 1.6 to 3.9 kg (mean, 2.8 kg; median, 2.8 kg) and 3 patients weighed less than 2.0 kg. Twelve patients underwent mechanical ventilation before the operation, and all but 1 patient received an infusion of alprostadil (prostaglandin E1).
Operative procedure
Arterial blood pressure monitoring lines were placed in the right radial artery and femoral artery in each patient preoperatively. Through a midline sternotomy, the thymus gland was excised. The aortic arch, its branches, and the ductus arteriosus were dissected out. Dual arterial cannulas were inserted into the ductus arteriosus and into a 3.5-mm PTFE tube (Gore-Tex, W. L. Gore & Associates, Inc, Flagstaff, Ariz) that was anastomosed to the innominate artery. After insertion of a venous cannula into the right atrium, cardiopulmonary bypass was commenced at a flow rate of 150 to 180 mL/min per kilogram (Figure 1).
The branch right and left pulmonary arteries were temporarily occluded with tourniquets and systemic cooling was initiated.
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At a nasopharyngeal temperature of less than 22°C, the descending aorta was clamped. After removal of the perfusion cannula from the duct, all duct tissue was excised from the descending aorta. The left carotid artery and left subclavian artery were snared. Isolated cerebral and myocardial perfusion was established by placing a clamp just distal to the innominate artery.14,15 With the heart beating, the aortic arch was opened inferiorly and the back wall of the descending aorta was anastomosed to the posterior wall of the aortic arch.
At this stage, cold crystalloid cardioplegic solution (30 mL/kg) was administered over 3 minutes either from the aortic root or from a side port of the arterial cannula during temporary total circulatory arrest. The innominate artery was snared proximal to the perfusion site, and the clamp on the arch was removed. Cardiopulmonary bypass was resumed for isolated cerebral perfusion through the innominate artery. The aortic arch reconstruction was carried out by means of Brawn’s modification.3 The opening of the aortic arch was extended down into the ascending aorta to the level of the transected end of the main pulmonary artery. The proximal main pulmonary artery was directly anastomosed to the transverse arch and the opened-out ascending aorta (Figure 3).
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Echocardiographic assessment and late management
To evaluate diastolic reverse flow and the pressure gradient across the nonvalved RV-PA shunt, sequential Doppler echocardiography was performed in 7 patients at postoperative months 1 and 4 before stage II palliation. A spectral time-velocity display was obtained at the middle point of the RV-PA shunt. The velocity-time integrals of reverse and forward flow were measured by tracing the curves above and below the spectral baseline, respectively. The velocity-time integrals of the diastolic reverse flow were divided by the velocity-time integrals of systolic forward flow for calculation of the Doppler flow reversal ratio. Elective cardiac catheterization was carried out 3 to 4 months after stage I palliation. Results are expressed as mean ± SD. The Wilcoxon signed-rank test was used for comparison of data between postoperative months 1 and 4.
When patients presented with progressive desaturation, the stage II bidirectional Glenn (BDG) procedure was performed with or without cardiopulmonary bypass. The RV-PA was left open as an additional pulmonary blood supply. The stage III Fontan procedure was performed at approximately 2 years of age. A lateral tunnel cavopulmonary connection was constructed by means of a PTFE patch or a right atrial flap without fenestration.
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Results |
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The mean Doppler flow reversal ratio in the RV-PA shunt decreased from 0.28 ± 0.03 at 1 postoperative month to 0.16 ± 0.02 at 4 months (n = 7, P = .027), while the mean pressure gradient across the shunt increased from 34 ± 10 mm Hg to 58 ± 14 mm Hg (P = .018). At the same time, the mean transcutaneous oxygen saturation decreased from 82 ± 7% to 70 ± 8% (P = .018). Cardiac catheterization and cineangiography before stage II palliation (Figure 5) demonstrated that the mean pulmonary artery pressure was 11 ± 2 mm Hg (n = 13; range, 9 to 15 mm Hg) and the mean PA index16 measured was 215 ± 96 (range, 117 to 458).
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Discussion |
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The results of the present study have clearly shown differences in postoperative hemodynamics between the systemic-pulmonary shunt and the RV-PA shunt. Without delicate manipulation of systemic and pulmonary vascular resistance, the RV-PA shunt using a nonvalved PTFE conduit provides a stable systemic circulation as well as adequate pulmonary blood flow after stage I palliation. Although we have not determined an optimal size for the RV-PA shunt, our current choice of shunt is a 5-mm PTFE tube for patients weighing more than 2 kg and a 4-mm tube for patients less than 2 kg. These sizes of shunts are almost equivalent to 50% of the predicted normal size of the main pulmonary artery.19 From an anatomic point of view, therefore, HLHS hearts after aortic reconstruction with the main pulmonary artery and placement of an RV-PA shunt are similar to univentricular hearts with pulmonary stenosis. In this anatomic setting, pulmonary blood flow is limited by the size of the shunt, and systemic circulation, including coronary perfusion, theoretically cannot be compromised by changes in pulmonary vascular resistance. Our hypothesis was confirmed in other type of single-ventricle physiology as well. We have applied the RV-PA shunt in 2 newborn infants with heterotaxy syndrome, pulmonary atresia, and infracardiac type total anomalous pulmonary venous connection. Postoperative hemodynamics of these patients was also stable and both survived.
Excellent hemodynamics provided by the RV-PA shunt is particularly beneficial for low-birth-weight infants undergoing stage I palliation. Reported survival for patients weighing less than 2.5 kg after the Norwood procedure is still high (45% to 51%).20,21 Even the smallest 3-mm PTFE tube may be too large to limit pulmonary blood flow through the systemic-pulmonary shunt in this subgroup of patients. Because of the lack of suitably sized material, a standard Blalock-Taussig shunt has been the alternative method for very-low-weight infants.4,22 In the present series, the 3 infants weighing less than 2 kg received a 4-mm RV-PA shunt and all survived without any hemodynamic instability or right ventricular dysfunction.
The effects of a right ventriculotomy for the placement of the RV-PA shunt on systemic right ventricular function are of great concern. During early- to medium-term follow-up, right ventricular function evaluated by echocardiography was acceptable, and its fractional shortening in the 4 patients who had undergone the Fontan procedure was higher than 30%. In addition, ventricular arrhythmias were not found in any of the survivors. Another concern is related to the degree of flow reversal in the nonvalved RV-PA shunt. Doppler echocardiography demonstrated the greatest reversal flow ratio within 1 month after surgery, but all patients tolerated this volume overload well, maintaining reasonable oxygen saturation levels.
The lessons learned from 4 years of experience with the modified Norwood procedure using the RV-PA shunt are twofold. First, the nonvalved PTFE RV-PA shunt becomes obstructive with time, particularly from 3 months after surgery, as evidenced by the decrease in oxygen saturation and increase in the pressure gradient across the shunt. As 2 patients in the early series died from progressive shunt obstruction after hospital discharge, we are now very careful when patients’ oxygen saturations start decreasing. We have not used a larger shunt, such as 6-mm or 8-mm PTFE tube, because effect of a larger ventriculotomy on ventricular function is unclear. Second, pulmonary artery growth in patients who received the RV-PA shunt is not as well as in those who had a systemic-to-pulmonary shunt, indicating that the RV-PA shunt provides less pulmonary blood flow than the systemic-to-pulmonary shunt. However, resultant lower pulmonary vascular resistance made the BDG and subsequent Fontan procedures possible, even in patients with a PA-index of 200 or less.
In conclusion, the RV-PA shunt in stage I palliation provides stable hemodynamics and fine control of systemic and pulmonary resistance without extensive postoperative medical intervention. This novel procedure may be particularly beneficial to low-birth-weight infants with HLHS. However, it is cautioned that the RV-PA shunt becomes obstructive with time. We believe that improvement in survival for infants undergoing stage I palliation for HLHS would be reproducible for many less experienced surgeons with application of the RV-PA shunt.
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Discussion |
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Placing the pulmonary and systemic circulations in parallel rather than in series may have certain advantages. Imbalance of pulmonary and systemic blood flows is the leading cause of morbidity and mortality after the Norwood procedure. Most centers accomplish balance by manipulating vascular resistance. Dr Sano’s patients required no such manipulation, which resulted in a more predictable postoperative recovery.
The pulmonary bed was not subjected to nor dependent on diastolic flow, and there should be less change in pulmonary blood flow with pulmonary hypertensive crises or during resuscitation in the presence of low cardiac output or after a cardiac arrest.
There may, however, be deleterious effects with an additional volume load on the ventricle from regurgitation through the RV-PA shunt. This may result in ventricular dilatation and tricuspid regurgitation. A number of patients presented here had tricuspid regurgitation after stage I, although the incidence was less than preoperatively.
Dr Sano used larger 4- and 5-mm shunts and achieved balanced pulmonary and systemic circulations without overperfusion of the lungs. With larger shunts, less precision in gauging the size of the shunt should be needed and this might avoid some early reoperations for shunt change. Also, with a larger shunt, there should be a greater shunt longevity as well as a slower and more predictable shunt closure pattern. Such was not the case here in that 2 patients died late due to acute shunt closure and 7 others studied by echocardiography showed progressive shunt narrowing within 4 months.
I have a few questions.
Did the shunt regurgitation cause an increase in tricuspid regurgitation in any patient and did you have to repair the tricuspid valve at stage II in any patient?
Why did you leave the shunt patent, as stated in your manuscript, after stage II? Were the 2 deaths after stage II related to residual shunt patency or tricuspid regurgitation? Did any patients after stage II have prolonged pleural drainage?
In the manuscript you state that your survival was 53% before you used the RV-PA shunt and 89% with the RV-PA shunt. Did you analyze the two groups for other factors that might have accounted for your improved survival?
Dr Sano, your presentation was clear, your manuscript was well written, and you have made a compelling argument for the use of the RV-PA shunt in the Norwood procedure. This information should be useful to surgeons in considering various options for babies with HLHS, and I thank you for bringing this information to this meeting.
Dr Sano. Thank you, Dr Litwin, for your comments.
Regarding your first question, we also were concerned about volume loading due to shunt regurgitation through a nonvalved conduit. This was also why we used a 4-mm PTFE graft rather than a 5-mm graft initially.
However, we found that the regurgitant flow was not as much as we expected. Rather than volume loading, we found that the 4-mm graft became stenotic very quickly. Therefore, we lost 2 patients out of 5 who had a 4-mm PTFE graft.
As I presented, regurgitant flow was 28% 2 weeks postoperatively, and this gradually decreased to 16% 4 months postoperatively. Tricuspid valve repair due to dilatation of the ventricle was not necessary.
Regarding the second question, I left the shunt open because at the time of BDG, the graft itself became smaller with some forward flow to the pulmonary artery, especially to the left. Therefore, saturation is little, but higher than that of a usual BDG and the left PA grows more. This is also the advantage of the RV-PA shunt.
Dr Litwin. In your manuscript you stated that your mortality statistics were much improved with the RV-PA shunt as compared with results in the previous patients. I wondered whether you looked at other factors that might have accounted for improved survival other than the use of the RV-PA shunt?
Dr Sano. Before 1998, I was doing the classic Norwood procedure with a mortality of 50%. Achievement of the Fontan procedure in the patients who underwent the classic Norwood was less than 30%.
One big change during the initial period was to adopt cerebral and myocardial perfusion to avoid deep hypothermia and circulatory arrest, stated in 1995. However, I think the result was not different from and after 1995. A dramatic change has occurred since 1998, when we started using the RV-PA shunt as a first palliation for HLHS.
Dr Constantine Mavroudis. Dr Sano, why was there a difference?
Dr Sano. Because diastolic pressure was higher after the RV-PA shunt Norwood. Also, in the classic Norwood, it is not easy to make a balance between systemic and pulmonary circulation. Also, I think that if diastolic pressure is high, coronary perfusion should be better.
Dr Litwin. What was the cause of the 2 deaths after stage II?
Dr Sano. One was viral pneumonia and the other was due to progressive hyopxemia.
Mr Marco Pozzi (Liverpool, United Kingdom). Over the past 6 months I have also introduced this technique into my experience and it has made a dramatic difference. I parallel his experience. We have had no mortality since we introduced this technique. In particular, the management of the patient has become much simpler. Indeed, our major problem in terms of mortality after the Norwood operation was often due to postoperative mismanagement. As with this technique, management has become simple. We find that we do not require any more the degree of expertise.
The other important issue was the concern from the cardiologist’s point of view that introducing a ventriculotomy could have affected the long-term result. However, so far all the echocardiographic investigation on this patient would suggest that ventricular function is absolutely indistinguishable from any other good patient after a classic type of Norwood repair. I certainly parallel Dr Sano’s experience and confirm the validity of this technique.
Dr Christian Pizarro (Wilmington, Del). We have had similar experience, which currently includes 34 patients with only 3 deaths. At this time, 18 patients have completed a second stage and there has been no interstage mortality.
I just have one question. Have you used this new procedure for patients with morphologic single left ventricle? If so, have you had any trouble with the inflow into the shunt due to muscle growth over time?
Dr Sano. Yes, in 1 patient. I could not find any good place to do a ventriculotomy due to the ventricular septum, so I did a classic Norwood.
Dr Francois Lacour-Gayet (Hamburg, Germany). I consider this an important innovation. Since I have used this technique in the last 5 patients, I have seen a totally different postoperative course. As a matter of fact, you can reproduce this beneficial effect in doing an RV-PA anastomosis in pulmonary atresia and ventricular septal defect. This is a similar physiology and this shunt works the same way.
I would like to comment a bit more on the second quality of this anastomosis. I think this technique may solve the problem of the left pulmonary artery in the Norwood procedure. There are a number of publications showing that the left pulmonary artery is sometimes hypoplastic. In a classic Norwood operation, the left pulmonary artery has a tendency to go back in the posterior part of the pericardium. Your shunt has the advantage to hold it. I have recently done a Glenn anastomosis after an RV-PA shunt. On the angiogram, I was very happy to see that the left pulmonary artery was even bigger than the right, and I think that this is a big change.
I have one last question. What do you think about valvulation of the shunt in the future?
Dr Sano. Dr Norwood performed the RV-PA shunt using a valved conduit; however, the graft was too big at that time and there was no survival. Theoretically, it is better to have a valve in the RV-PA graft; however, it should be the same or similar size of 5-mm PTFE graft. If there is such an ideal graft with a valve, I will certainly try to use it.
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N. S. Ghanayem, R. D.B. Jaquiss, J. R. Cava, P. C. Frommelt, K. A. Mussatto, G. M. Hoffman, and J. S. Tweddell Right Ventricle-to-Pulmonary Artery Conduit Versus Blalock-Taussig Shunt: A Hemodynamic Comparison Ann. Thorac. Surg., November 1, 2006; 82(5): 1603 - 1610. [Abstract] [Full Text] [PDF]
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R. D.B. Jaquiss, S. L. Siehr, N. S. Ghanayem, G. M. Hoffman, R. T. Fedderly, J. R. Cava, K. A. Mussatto, and J. S. Tweddell Early Cavopulmonary Anastomosis After Norwood Procedure Results in Excellent Fontan Outcome. Ann. Thorac. Surg., October 1, 2006; 82(4): 1260 - 1266. [Abstract] [Full Text] [PDF]
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J. J. Nigro and J. Graziano Reply. Ann. Thorac. Surg., September 1, 2006; 82(3): 1169 - 1169. [Full Text] [PDF]
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 K. Booth Surgical Outcome for Hypoplastic Left Heart Syndrome AAP Grand Rounds, September 1, 2006; 16(3): 29 - 30. [Full Text] [PDF]
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S. Kats, P. L. de Jong, M. Witsenburg, and A. J.J.C. Bogers Massive haemorrhage at resternotomy after stent implantation in ventriculo-pulmonary shunt after Norwood procedure Interactive CardioVascular and Thoracic Surgery, June 1, 2006; 5(3): 234 - 235. [Abstract] [Full Text] [PDF]
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S. P. McGuirk, J. Stickley, M. Griselli, O. F. Stumper, S. J. Laker, D. J. Barron, and W. J. Brawn Risk assessment and early outcome following the Norwood procedure for hypoplastic left heart syndrome Eur. J. Cardiothorac. Surg., May 1, 2006; 29(5): 675 - 681. [Abstract] [Full Text] [PDF]
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J. G. Berry, C. G. Cowley, C. J. Hoff, and R. Srivastava In-Hospital Mortality for Children With Hypoplastic Left Heart Syndrome After Stage I Surgical Palliation: Teaching Versus Nonteaching Hospitals Pediatrics, April 1, 2006; 117(4): 1307 - 1313. [Abstract] [Full Text] [PDF]
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J. Photiadis, B. Asfour, N. Sinzobahamvya, C. Fink, E. Schindler, A.-M. Brecher, and A. E. Urban Improved Hemodynamics and Outcome After Modified Norwood Operation on the Beating Heart Ann. Thorac. Surg., March 1, 2006; 81(3): 976 - 981. [Abstract] [Full Text] [PDF]
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 S P McGuirk, M Griselli, O F Stumper, E M Rumball, P Miller, R Dhillon, J V de Giovanni, J G Wright, D J Barron, and W J Brawn Staged surgical management of hypoplastic left heart syndrome: a single institution 12 year experience Heart, March 1, 2006; 92(3): 364 - 370. [Abstract] [Full Text] [PDF]
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M. Griselli, S. P. McGuirk, O. Stumper, A. J.B. Clarke, P. Miller, R. Dhillon, J. G.C. Wright, J. V. de Giovanni, D. J. Barron, and W. J. Brawn Influence of surgical strategies on outcome after the Norwood procedure J. Thorac. Cardiovasc. Surg., February 1, 2006; 131(2): 418 - 426. [Abstract] [Full Text] [PDF]
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C. D. Myers, J. H. Boyd, R. G. Presson Jr, P. Vijay, A. C. Coats, J. W. Brown, and M. D. Rodefeld Neonatal Cavopulmonary Assist: Pulsatile Versus Steady-Flow Pulmonary Perfusion Ann. Thorac. Surg., January 1, 2006; 81(1): 257 - 263. [Abstract] [Full Text] [PDF]
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C. D. Myers, K. Mattix, R. G. Presson Jr, P. Vijay, D. Maynes, K. N. Litwak, J. W. Brown, and M. D. Rodefeld Twenty-Four Hour Cardiopulmonary Stability in a Model of Assisted Newborn Fontan Circulation Ann. Thorac. Surg., January 1, 2006; 81(1): 264 - 271. [Abstract] [Full Text] [PDF]
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S. Tabbutt, T. E. Dominguez, C. Ravishankar, B. S. Marino, P. J. Gruber, G. Wernovsky, J. W. Gaynor, S. C. Nicolson, and T. L. Spray Outcomes After the Stage I Reconstruction Comparing the Right Ventricular to Pulmonary Artery Conduit With the Modified Blalock Taussig Shunt Ann. Thorac. Surg., November 1, 2005; 80(5): 1582 - 1591. [Abstract] [Full Text] [PDF]
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J. J. Nigro, R. D. Bart, C. D. Derby, M. S. Sklansky, and V. A. Starnes Proximal Conduit Obstruction After Sano Modified Norwood Procedure Ann. Thorac. Surg., November 1, 2005; 80(5): 1924 - 1928. [Abstract] [Full Text] [PDF]
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A. S. Mackie, K. L. Booth, J. W. Newburger, K. Gauvreau, S. A. Huang, P. C. Laussen, J. A. DiNardo, P. J. del Nido, J. E. Mayer Jr, R. A. Jonas, et al. A randomized, double-blind, placebo-controlled pilot trial of triiodothyronine in neonatal heart surgery J. Thorac. Cardiovasc. Surg., September 1, 2005; 130(3): 810 - 816. [Abstract] [Full Text] [PDF]
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C. L. Cua, R. R. Thiagarajan, R. Taeed, T. M. Hoffman, L. Lai, J. Hayes, P. C. Laussen, and T. F. Feltes Improved Interstage Mortality With the Modified Norwood Procedure: A Meta-Analysis Ann. Thorac. Surg., July 1, 2005; 80(1): 44 - 49. [Abstract] [Full Text] [PDF]
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K. Januszewska, J. Kolcz, T. Mroczek, M. Procelewska, and E. Malec Right ventricle-to-pulmonary artery shunt and modified Blalock-Taussig shunt in preparation to hemi-Fontan procedure in children with hypoplastic left heart syndrome Eur. J. Cardiothorac. Surg., June 1, 2005; 27(6): 956 - 961. [Abstract] [Full Text] [PDF]
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E. M. Rumball, S. P. McGuirk, O. Stumper, S. J. Laker, J. V. de Giovanni, J. G. Wright, D. J. Barron, and W. J. Brawn The RV-PA conduit stimulates better growth of the pulmonary arteries in hypoplastic left heart syndrome Eur. J. Cardiothorac. Surg., May 1, 2005; 27(5): 801 - 806. [Abstract] [Full Text] [PDF]
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D. J. DiBardino, J. S. Heinle, D. A. Andropoulos, C. D. Kerr, D. L. S. Morales, and C. D. Fraser Jr Aortic Atresia and Type B Interrupted Aortic Arch: Diagnosis by Physiologic Cerebral Monitoring Ann. Thorac. Surg., May 1, 2005; 79(5): 1758 - 1760. [Abstract] [Full Text] [PDF]
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P. A. Checchia, J. McCollegan, N. Daher, N. Kolovos, F. Levy, and B. Markovitz The effect of surgical case volume on outcome after the Norwood procedure J. Thorac. Cardiovasc. Surg., April 1, 2005; 129(4): 754 - 759. [Abstract] [Full Text] [PDF]
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U Theilen and L Shekerdemian The intensive care of infants with hypoplastic left heart syndrome Arch. Dis. Child. Fetal Neonatal Ed., March 1, 2005; 90(2): F97 - F102. [Abstract] [Full Text] [PDF]
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A. S. Batra, V. A. Starnes, and W. J. Wells Does the Site of Insertion of a Systemic-Pulmonary Shunt Influence Growth of the Pulmonary Arteries? Ann. Thorac. Surg., February 1, 2005; 79(2): 636 - 640. [Abstract] [Full Text] [PDF]
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S. Sano, K. Ishino, H. Kado, Y. Shiokawa, K. Sakamoto, M. Yokota, and M. Kawada Outcome of Right Ventricle-to-Pulmonary Artery Shunt in First-Stage Palliation of Hypoplastic Left Heart Syndrome: A Multi-Institutional Study Ann. Thorac. Surg., December 1, 2004; 78(6): 1951 - 1958. [Abstract] [Full Text] [PDF]
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C. Pizarro, T. Mroczek, E. Malec, and W. I. Norwood Right Ventricle to Pulmonary Artery Conduit Reduces Interim Mortality After Stage 1 Norwood for Hypoplastic Left Heart Syndrome Ann. Thorac. Surg., December 1, 2004; 78(6): 1959 - 1964. [Abstract] [Full Text] [PDF]
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Y. Tanoue, H. Kado, Y. Shiokawa, N. Fusazaki, and S. Ishikawa Midterm Ventricular Performance After Norwood Procedure With Right Ventricular-Pulmonary Artery Conduit Ann. Thorac. Surg., December 1, 2004; 78(6): 1965 - 1971. [Abstract] [Full Text] [PDF]
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K. N. Fenton, F. A. Pigula, S. K. Gandhi, L. Russo, and K. F. Duncan Interim Mortality in Pulmonary Atresia With Intact Ventricular Septum Ann. Thorac. Surg., December 1, 2004; 78(6): 1994 - 1998. [Abstract] [Full Text] [PDF]
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L. A Vricella, P. Samankatiwat, M. R de Leval, V. T Tsang, and P. R Vouhe Simplified Antegrade Cerebral Perfusion and Myocardial Protection during Stage I Norwood Procedure Asian Cardiovasc Thorac Ann, December 1, 2004; 12(4): 372 - 373. [Abstract] [Full Text] [PDF]
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S. M. Bradley, J. M. Simsic, T. C. McQuinn, D. M. Habib, G. S. Shirali, and A. M. Atz Hemodynamic status after the Norwood procedure: A comparison of right ventricle-to-pulmonary artery connection versus modified blalock-taussig shunt Ann. Thorac. Surg., September 1, 2004; 78(3): 933 - 941. [Abstract] [Full Text] [PDF]
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A. Azakie, D. Martinez, A. Sapru, J. Fineman, D. Teitel, and T. R. Karl Impact of right ventricle to pulmonary artery conduit on outcome of the modified norwood procedure Ann. Thorac. Surg., May 1, 2004; 77(5): 1727 - 1733. [Abstract] [Full Text] [PDF]
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M. D. Rodefeld, J. H. Boyd, C. D. Myers, R. G. Presson Jr, W. W. Wagner Jr, and J. W. Brown Cavopulmonary assist in the neonate: an alternative strategy for single-ventricle palliation J. Thorac. Cardiovasc. Surg., March 1, 2004; 127(3): 705 - 711. [Abstract] [Full Text] [PDF]
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J. M. Forbess Pre-stage II mortality after the Norwood operation: Addressing the next challenge J. Thorac. Cardiovasc. Surg., November 1, 2003; 126(5): 1257 - 1258. [Full Text] [PDF]
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J. M. Pearl Right ventricular-pulmonary artery connection in stage 1 palliation of hypoplastic left heart syndrome J. Thorac. Cardiovasc. Surg., November 1, 2003; 126(5): 1268 - 1270. [Full Text] [PDF]
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