Operative Techniques in Thoracic and Cardiovascular Surgery最新文献

Norwood operation for patients with hypoplastic left heart syndrome or its variants may be associated with prolonged period of myocardial ischemia, particularly in those, who may require associated neo-aortic valve repair. Using the myocardial perfusion technique described herein, the heart could remain beating in normal sinus rhythm during the entire procedure, including neo-aortic valve repair and root reconstruction, and the need for cardioplegic heart arrest can be eliminated.

The Norwood procedure can be performed with several variations including a sustained total all-region (STAR) perfusion technique, introduced at our institution 5 years ago and well described in a prior Operative Techniques article. Regardless of technique heterogeneity, national outcomes continue to demonstrate that the Norwood procedure carries one of the highest mortalities of all congenital heart operations. Our technique of STAR perfusion provides total body perfusion during the entire Norwood reconstruction, avoiding coagulopathy associated with significant cooling and ischemic time to end-organs. Over the past few years, we have refined the technique, and describe key variations and modifications in this article.

Percutaneously placed veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is commonly used to support patients with refractory cardiac arrhythmias or arrest and worsening cardiogenic shock. Peripheral VA-ECMO by retrograde flow of blood in the aorta results in a significant increase in left ventricle (LV) afterload. A severely dysfunctional LV may be unable to overcome this afterload to open the aortic valve and unload itself. This may lead to LV distension, increased LV pressure, poor coronary blood circulation, increased left atrial pressures, pulmonary edema, and pulmonary hypertension. Moreover, it jeopardizes ventricular recovery, particularly in the presence of ischemia-induced myocardial impairment. Furthermore, if the aortic valve remains closed during the cardiac cycle, stasis of blood in the LV and aortic root may increase the risk of thrombus formation. These complications may preclude cardiac recovery and the patient from being a heart transplant candidate. In patients with cardiogenic shock, utilizing Impella with VA-ECMO, commonly referred to as ECPella, has consistently been shown to reduce mortality and improve outcomes. Patients who need prolonged ECPella support as a bridge to recovery or transplant may remain bed-bound since ambulation of patients with 2 mechanical circulatory support devices is challenging. We present the technique of ECPella placement through Y chimney graft anastomosis on the axillary artery for arterial cannula and Impella insertion and percutaneous cannulation of the right internal Jugular vein for venous cannula. This technique gives the ease of ambulation and decannulation of VA-ECMO under local anesthesia without requiring intubation or a trip to the operating room.

Use of a valved Sano (VS) during the Norwood procedure has been reported previously, but is not widely used and its impact on clinical outcomes needs to be further elucidated. Our institution shifted practice to the VS operation entirely in 2019, using a valved femoral venous homograft. We describe our technique in the present report. The VS technique is well codified and highly reproducible. Pre-Glenn echocardiograms showed competent conduit valves in two-thirds of the VS patients (n = 16/25, 66.7%). We retrospectively reviewed 25 consecutive HLHS neonates who underwent a Norwood procedure with a VS conduit using a femoral venous homograft and 25 consecutive HLHS neonates who underwent a Norwood procedure with a non-valved Sano (NVS) conduit between 2013 and 2022. Hospital survival for the VS group was 96%. Postoperatively, VS patients had significantly lower peak and postoperative day 1 lactate levels (p = 0.033 and p = 0.025 respectively), shorter time to diuresis (p = 0.043), and shorter time to enteral feeds (p = 0.038). The VS group had significantly fewer PA reinterventions until the Glenn (n = 1 vs 8; p = 0.044). The VS group showed significant improvement in ventricular function from the immediate postoperative period to discharge (p < 0.001). From preoperative to pre-Glenn time points, analysis of ventricular function showed sustained ventricular function within the VS group, but a significant reduction of ventricular function in the NVS group (p = 0.003). The use of a valved conduit for Norwood-Sano procedure is a reproducible technique, associated with improved multi-organ recovery, ventricular function recovery and fewer PA reinterventions.

Arch reconstruction as part of the Norwood Procedure is a challenging 3-dimensional task that has to combine the aortic and pulmonary roots in a Damus-Kaye-Stansel anastomosis and also reconstruct the hypoplastic aortic arch, usually with concomitant coarctation. Compression or torsion of the aortic root can compromise coronary blood flow, especially in the setting of a diminutive native aortic root. This technique focuses on maximum augmentation of the aortic root with separate implantation of the pulmonary root into the reconstructed aortic arch – this maintains the natural spatial relationship of the aortic and pulmonary roots. The technique has the advantage of being reproducible across all morphological variants in hypoplastic left heart syndrome as well as in other situations where the Norwood is used such as with transposed great arteries and interrupted aortic arch.