Original article: cardiovascular
Routine mechanical ventricular assist following the Norwood procedure—improved neurologic outcome and excellent hospital survival

Presented at the Forty-ninth Annual Meeting of the Southern Thoracic Surgical Association, Miami, FL, Nov 7–9, 2002.
https://doi.org/10.1016/S0003-4975(03)01365-1Get rights and content

Abstract

Background

Although excellent survival following the Norwood procedure for palliation of hypoplastic left heart syndrome (HLHS) is being achieved by some, most centers, especially the ones with small surgical volume and limited experience, continue to struggle with initial results. Survivors often showed evidence of significant neurologic injury. The early postoperative care is labor-intensive as attempts are made to balance the systemic and pulmonary circulation for these infants. We report our experience with routine use of mechanical circulatory assist to support the increased cardiac output requirements present following Norwood procedure.

Methods

Eighteen consecutive infants undergoing Norwood operation for HLHS (Oregon Health & Science University [OHSU] 13; University of Louisville [UL] 5) were placed on a ventricular assist device (VAD) immediately following modified ultrafiltration in the operating room using the cardiopulmonary bypass (CPB) cannulas that were in the right atrium and the neoaorta. VAD flows were maintained at approximately 200 mL · kg−1 · min−1 and the patients were transported to the intensive care unit (ICU). Patients operated at OHSU also received neurodevelopmental testing before their Glenn procedure, approximately 4 to 6 months following their Norwood operation.

Results

All patients were stable on VAD support and no attempt was made to balance the systemic and pulmonary circulation. The ventilator was manipulated to achieve systemic Pa02 between 30 and 45 mm Hg and PaC02 between 35 and 45 mm Hg. Evidence of hypoperfusion (increasing lactates) was managed by increasing the VAD flow. Lactates normalized [< 2 mmol/L]) by 1.8 ± 1.1 days following surgery. Average time of VAD support was 3.1 ± 1.0 (range, 2 to 5 days) and average time until chest closure was 3.4 ± 1.5 (range, 2 to 8 days). There were two cases of postoperative bleeding (11.1%) requiring reexploration and one case of mediastinitis (5.5%) in a patient who has now gone on to successful Glenn. Sixteen of the eighteen patients survived (hospital survival mean 89% with a 95% confidence interval of 63.9% to 98.1%; 12/13 OHSU [92.3%]; 4/5 UL [80%]). Neurodevelopmental testing using the Mullen Scales of Early Learning and the Vineland Adaptive Behavior Scale were normal for all infants tested.

Conclusions

Routine postoperative use of VAD can support the increased cardiac output demands of infants following Norwood operation and results in a stable postoperative convalescence that does not require aggressive ventilator or inotrope manipulation. Although not a panacea, this strategy can simplify postoperative management, lead to excellent hospital survival, and possibly augment cerebral oxygen delivery, resulting in improved neurologic outcomes for this challenging group of patients.

Section snippets

Material and methods

Beginning in January, 2001, thirteen consecutive infants at Doernbecher Children's Hospital (Oregon Health & Science University, Portland, Oregon [OHSU]) and five at Kosair Children's Hospital (University of Louisville, Louisville, Kentucky [UL]) underwent Norwood for HLHS or Damus-Kaye-Stansel (with arch augmentation) for variations of HLHS (Table 1). They were routinely placed on mechanical ventricular assist immediately at the end of their procedure. Institutional Review Board approval was

Results

All patients were successfully weaned off from ventricular support (Table 3), but two patients (both nonsurvivors) had hemodynamic instability and required urgent replacement on mechanical support within a short time of removal from VAD. All the others recovered and were eventually discharged from the hospital (hospital survival 16/18 = 89% with 95% confidence interval of 63.9% to 98.1%). Complications related to VAD were minimal. One patient (OHSU) developed mediastinal infection and was

Comment

Despite recent improvement in outcomes at some institutions, hospital survival following Norwood procedure continues to present a challenge to many centers 3, 9, 20. Three-year survival is approximately 66% even in the most experienced centers 10, 21. Reasons for late mortality may relate in part to shunt thrombosis, coronary insufficiency, mortality from subsequent procedures, and complications from neurologic impairment. Furthermore, the quality of neurologic outcome is questionable for many

Acknowledgements

As in any multi-institutional study, active participation is provided by more individuals than can be realistically included in the list of authors. The authors gratefully appreciate the significant input from numerous others, including (and not limited to) Dana Braner, MD, Robert Steelman, MD, Laura Ibsen, MD, Miles Ellenby, MD, Aileen Kirby, MD, Kenneth Tegtmeyer, MD, Grant Burch, MD, Mark Reller, MD, Mary Rice, MD, Paul Droukas, MD, Seshardri Balaji, MD, Mary Minette, MD, Brent Barber, MD,

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