Posterior Reduction Aortoplasty for Left Pulmonary Artery Compression After Norwood Procedure

doi:10.1016/j.athoracsur.2010.10.016

The Annals of Thoracic Surgery

Volume 91, Issue 4, April 2011, Pages 1300-1301

https://doi.org/10.1016/j.athoracsur.2010.10.016 Get rights and content

All patients following the Norwood I procedure have a very large ascending aorta. This can lead to extrinsic compression of the surrounding vessels. We report a case of left pulmonary artery compression secondary to an aneurysmal neo-aorta and describe a technique of posterior reduction aortoplasty to decompress the left pulmonary artery.

Section snippets

Technique

While on hypothermic cardiopulmonary bypass with the aorta clamped just beneath the aortic arch, and with the heart cardiopleged, the aorta was transected just above the sinuses of the aortic root. The posterior sinus of the ascending aorta (the old pulmonary artery) was resected, and the posterior aortic walls were sutured longitudinally to create a posterior space. In doing this procedure, the proximal orifice of the ascending aorta was relocated anteriorly. Likewise, tissue was resected from

Comment

Left pulmonary artery stenosis can complicate the stage I Norwood procedure for hypoplastic left heart syndrome [1, 2, 3], and in this case, double-inlet left ventricle. The stenosis may be due to a combination of factors. Residual duct tissue in the reconstruction may create an intrinsic stenosis, repair of the pulmonary artery with patch tissue may result in narrowing, and there may be twisting or torsion of the vessel itself [1]. However, the Damus-Kaye-Stansel reconstruction of the proximal

References (4)

N.C. Poirier et al.
Modified Norwood procedure with a high-flow cardiopulmonary bypass strategy results in low mortality without late arch obstruction
J Thorac Cardiovasc Surg
(2000)
D.P. Bichell et al.
Late left pulmonary artery stenosis after the Norwood procedure is prevented by a modification in shunt construction
Ann Thorac Surg
(2005)

There are more references available in the full text version of this article.

Cited by (9)

Modified Aortic Arch Reconstruction Combined With Pulmonary Artery Reconstruction in the Comprehensive Stage II Operation Following a Hybrid Stage I for Hypoplastic Left Heart Syndrome
2024, Operative Techniques in Thoracic and Cardiovascular Surgery
The hybrid approach for hypoplastic left heart syndrome is a well-accepted alternative strategy to the conventional staged surgical approach. However, in the typical comprehensive stage II operation, bilateral branch pulmonary artery stenosis is a risk factor for postoperative catheter and/or surgical interventions. In addition to addressing the stenosis from the bands, the branch pulmonary arteries are at risk of compression from the dilated main pulmonary trunk and the resultant large neo-aorta. Here, we present a new aortic arch reconstruction technique combined with the pulmonary artery reconstruction in the comprehensive stage II operation to address these issues. In our experience of 11 patients who underwent hybrid strategy, Fontan completion was achieved in 8 cases (73%) during a median follow-up duration of 84 months (range; 45-161 months), and the 3-year, 5-year, and 10-year survival rates were 73% each. While 6 of 8 cases (75%) required catheter interventions to the branch pulmonary arteries, the Nakata Index was 204 ± 11 before the stage II and 185 ± 19 before Fontan completion, indicating that good pulmonary artery growth. Our modified comprehensive stage II technique optimizes the pulmonary arteries for the Fontan and beyond by addressing both anatomic stenoses and external compression for future growth.
Commentary: Congenital aortic arch reconstruction: Keeping the window open
2021, JTCVS Techniques
Chimney reconstruction of the aortic arch in the Norwood procedure
2017, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
A late complication of neo-aortic root dilation that can cause this compression also has been observed.1 Both Baker's neo-aortic extension2 and Menon's posterior reduction of aortoplasty3 are effective salvage operations for releasing this compression. Our chimney reconstruction technique incorporates the benefits of these techniques, with longitudinal extension and horizontal plication of the pulmonary trunk accomplishing a wide aortopulmonary space, as well as preventing future dilatation of the neo-aortic root.4
Aortic arch geometry after the Norwood procedure: The value of arch angle augmentation
2015, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
Baker and colleagues27 reported ascending aortic extension to enlarge the aortopulmonary space in 3 patients with branch PA stenosis after the Norwood procedure. In addition, Menon and colleagues28 reported posterior reduction aortoplasty for neoaortic compression of the left PA after the Norwood procedure. In the present study, a total of 14 patients (38.9%) experienced reintervention/reoperation for bronchomalacia or branch PA stenosis postoperatively.
Aortic arch reconstruction in the Norwood procedure is occasionally associated with postoperative airway and branch pulmonary artery stenosis, as well as recoarctation. This study investigated geometric changes in the aortic arch after the Norwood procedure and evaluated the efficacy of arch angle augmentation with glutaraldehyde-treated autologous pericardium in aortic arch reconstruction.
Of 52 consecutive patients who underwent the Norwood procedure between 1998 and 2013, a total of 36 patients who underwent postoperative multidetector-row computed tomographic angiography were reviewed retrospectively, and divided into 2 groups according to whether arch angle augmentation with glutaraldehyde-treated autologous pericardium was performed (AAA group, 26 patients) or not (NA group, 10 patients).
The neoaortic arch in the Norwood procedure was characterized by having a significantly smaller angle, being lower in height, and being narrower than that in age-matched control patients with a normal aortic arch. Moreover, all of these arch geometric measurements were significantly larger in the AAA group than in the NA group. Freedom from reintervention and reoperation for bronchomalacia or branch pulmonary artery stenosis, caused by extrinsic compression of the neoaorta, was significantly better at 1 year in the AAA group than in the NA group. Recoarctation of the neoaorta was documented in only 1 (3.8%) patient in the AAA group versus 3 patients (30%) in the NA group.
Arch angle augmentation with glutaraldehyde-treated autologous pericardium in the Norwood procedure creates more aortopulmonary space with a smoother arch angle and diminished incidence of postoperative recoarctation, bronchial compression, or branch pulmonary artery compression.
Chimney reconstruction provides a wider subaortic space and reduces the risk of pulmonary artery compression in the Norwood-type aortic arch reconstruction without patch supplementation
2021, European Journal of Cardio-thoracic Surgery
Ascending aortic extension to enlarge the retroaortic space in children after the Norwood procedure
2021, General Thoracic and Cardiovascular Surgery

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How to do itPosterior Reduction Aortoplasty for Left Pulmonary Artery Compression After Norwood Procedure

Section snippets

Technique

Comment

J Thorac Cardiovasc Surg

Late left pulmonary artery stenosis after the Norwood procedure is prevented by a modification in shunt construction

Ann Thorac Surg

How to do it
Posterior Reduction Aortoplasty for Left Pulmonary Artery Compression After Norwood Procedure