Stage I Norwood: The Birmingham Children’s Hospital Approach

Arterial cannulation is performed in the distal ductus with venous return from the right atrial appendage. During cooling, the pulmonary artery end of the Blalock Taussig shunt is constructed as illustrated between the distal innominate artery and the right pulmonary artery using 8-0 Prolene. RPA = right pulmonary artery.

Location of incisions that will be made is indicated. Note that the juxtaductal coarctation area will be completely excised. Ao = aorta; Desc. Ao = descending aorta; IA = innominate artery; LPA = left pulmonary artery; MPA = main pulmonary artery; PDA = patent ductus arteriosus; PTFE = polytetrafluoroethylene; RAA = right atrial appendage; RPA = right pulmonary artery.

Excision of the juxtaductal coarctation region. The arch and ascending aorta have been filleted open. The distal divided main pulmonary artery is closed with a pulmonary homograft patch. MPA = main pulmonary artery.

(A) A direct anastomosis is fashioned between the proximal divided main pulmonary artery, the descending aorta, and the arch and ascending aorta. (B) The anterior suture line is completed without use of supplementary tissue.

Cannulation method for the rewarming phase following completion of the Norwood reconstruction. Note that the atrial septectomy and arch reconstruction was performed under hypothermic circulatory arrest. IA = innominate artery; LPA = left pulmonary artery; MPA = main pulmonary artery; PTFE = polytetrafluoroethylene; RA = right atrium; RPA = right pulmonary artery; SVC = superior vena cava artery.

The completed Norwood procedure using no supplementary tissue for arch reconstruction. RV = right ventricle; TV = tricuspid valve.

Both cerebral and coronary perfusion can be maintained by appropriate placement of tourniquets and clamps. Cardioplegia infusion can be infused as shown. The proximal main pulmonary artery is divided as shown and the distal divided main pulmonary artery is closed with a patch. If the coarctation tissue is exuberant and creates a marked coarctation ridge, then it is excised and the aorta reconstructed by suture.

The current technique at Birmingham Children’s Hospital continues to incorporate a homograft patch supplementing the neoaortic reconstruction. Different techniques for constructing a Sano type shunt are illustrated; however, the right-sided shunt is performed in the vast majority of patients.

Several patches of pulmonary homograft are harvested from one pulmonary valve and stored separately so that 4 or 5 patients can be operated on using only one valve. The pulmonary homograft patch is sutured to the undersurface of the aortic arch with or without coarctation resection to supplement the arch and reconstruct it.

The pulmonary homograft is sutured entirely to the proximal main pulmonary artery. There is no direct anastomosis between the original main pulmonary artery and the ascending aorta. LCC = left common carotid artery; RV = right ventricle; TV = tricuspid valve.

In the current technique at Birmingham Children’s Hospital an initial 3-mm Gortex tube graft is sutured to the innominate artery to allow perfusion during reconstruction. A second 4- or 5-mm Gortex tube graft is sutured to the right pulmonary artery as illustrated and will function as the Sano shunt. Innom. V. = innominate vein.

Although the technique initially involved anastomosis of the distal Sano shunt to the left side of the neoaorta, the technique has evolved so that presently the distal anastomosis is placed to the right side of the neoaorta. It was hoped that this technique would reduce the incidence of central pulmonary artery stenosis we observed with the left-sided Sano shunt and allow easier access to the central pulmonary arteries at the time of cavo-pulmonary shunt if pulmonary artery reconstruction was necessary. MPA = main pulmonary artery.