Re-Norwood operation using femoral artery cannulation

Re-Norwood operation is technically difficult to perform and is a high risk procedure due to the underlying hypocardiac function. Herein, we describe our successful re-Norwood operation approach in a 6-month old infant with persistent severe cyanosis and aortic re-coarctation. Our procedure was performed using femoral artery cannulation to protect cerebrospinal and lower body perfusion. Safe reopening of the chest was achieved, despite strong adhesions due to prior surgeries. Our repair and anastomosis techniques are described in detail. Cardiac circulation and function improved post-surgery. The patient was maintained on anti-heart failure drug therapy after surgery while awaiting a Glenn procedure.

The importance of gestational age as a prognostic factor on Norwood Stage 1 outcome

Objectives: The Norwood operation performed for hypoplastic left heart syndrome (HLHS) in the neonatal period remains to be a high-risk and difficult surgical procedure. It is known that preterm birth often accompanied by low birth weight is associated with high mortality and morbidity in these patients. Patients and Methods: The study included 54 patients who underwent the Norwood procedure in our clinic in the period between December 2012 and December 2019. Patient data were evaluated retrospectively; including gestational week, age, body weight, total bypass time, aortic cross-clamp time, extubation time, the length of stay in the intensive care unit, the length of hospital stay, and the preoperative and postoperative levels of urea, creatinine, ALT, AST, and platelet counts. Results: The body weight of the patients ranged from 2350 to 4500 grams with an average of 3296.3±486.7 grams. The age of the patients at the time of operation ranged from 1 to 374 days with an average of 30.31±70.51 days. The comparison of patients by term pregnancies resulted in no statistically significant differences but the comparison by gestational weeks revealed a statistically significant result. Conclusion: Preoperative risk factors affect prognosis more than the surgical technique and the treatment approach in patients with a functional single ventricle. When the gestational week was evaluated as a preoperative risk factor for its effects on the postoperative prognosis of stage 1 Norwood operation in our study, it was found that mortality decreased significantly after the 38.8th gestational week (272 gestational days).

Transient and persistent acute kidney injury phenotypes following the Norwood operation: a retrospective study

Background: Acute kidney injury is a common complication following the Norwood operation. Most neonatal studies report acute kidney injury peaking within the first 48 hours after cardiac surgery. The aim of this study was to evaluate if persistent acute kidney injury (>48 postoperative hours) after the Norwood operation was associated with clinically relevant outcomes. Methods: Two-centre retrospective study among neonates undergoing the Norwood operation. Acute kidney injury was initially identified as developing within the first 48 hours after cardiac surgery and stratified into transient (≤48 hours) and persistent (>48 hours) using the neonatal modification of the Kidney Disease: Improving Global Outcomes serum creatinine criteria. Severe was defined as stage ≥2. Primary and secondary outcomes were mortality and duration of ventilation and hospital length of stay. Results: One hundred sixty-eight patients were included. Transient and persistent acute kidney injuries occurred in 24 and 17%, respectively. Cardiopulmonary bypass and aortic cross clamp duration, and incidence of cardiac arrest were greater among those with persistent kidney injury. Mortality was four times higher (41 versus 12%, p < 0.001) and mechanical ventilation duration 50 hours longer in persistent acute kidney injury patients (158 versus 107 hours; p < 0.001). In multivariable analysis, persistent acute kidney injury was not associated with mortality, duration of ventilation or length of stay. Severe persistent acute kidney injury was associated with a 59% increase in expected ventilation duration (aIRR:1.59, 95% CI:1.16, 2.18; p = 0.004). Conclusions: Future large studies are needed to determine if risk factors and outcomes change by delineating acute kidney injury into discrete timing phenotypes.

Stent compression during resuscitation of a neonate with complex heart disease: fatal outcome

A newborn with hypoplastic left heart underwent a Norwood operation. Obstruction of the Blalock–Thomas–Taussig shunt was treated with a stent. During resuscitation, this was compressed, which contributed to a fatal outcome.

Assessment tool validation and technical skill improvement in the simulation of the Norwood operation using three-dimensional-printed heart models

OBJECTIVES The hands-on surgical training course utilizes 3-dimensional (3D)-printed heart models to simulate complex congenital heart operations. This study aimed to validate a model and assessment tool in the simulation of 2 techniques of the Norwood operation and investigate whether technical performance improves following rehearsal with or without proctor presence. METHODS Five ‘experienced’ and 5 ‘junior’ surgeons performed 2 techniques of the Norwood operation on 3D-printed models of hypoplastic left heart syndrome. Performances were retrospectively assessed by 10 raters with varying experience in congenital heart surgery (CHS) (Medical Doctorate versus non-Medical Doctorate). Assessments were made with the procedure-specific Hands-On Surgical Training-CHS tool. Results were analysed for technical performance and rater consistency. Following validation, 30 surgeons (24 with proctor guidance and 6 with training videos and objective feedback only) simulated the Norwood operation twice. RESULTS Performance scores were consistently higher for experienced surgeons and raters discriminated clearly between the experienced and junior surgeons (P ≤ 0.001). The hands-on surgical training-CHS tool showed high inter-rater (0.86) and intra-rater (0.80) reliability among all raters. Scores for both experienced and junior surgeons were highly consistent across all raters, with no statistically significant difference (P = 0.50). All surgeons successfully performed the Norwood operation. Sixty attempts were scored in total. Eighty-seven percentage (26/30) of surgeons’ scores (mean: attempt 1 = 92, attempt 2 = 104) and times [mean: attempt 1 = 1:22:00, attempt 2 = 1:08:00 (h:mm:ss)] improved between the 2 attempts by 9% and 15% respectively (P ≤ 0.001). Total scores of all surgeons in the non-proctored subgroup (6) improved by 15% on average (mean: attempt 1 = 86, attempt 2 = 105, P = 0.002). CONCLUSIONS Procedure-specific assessment tools can be developed to evaluate technical performance for complex CHS simulation and be performed reliably by non-expert raters. Rehearsal both under supervision and independently leads to technical skill improvement further supporting its value in CHS training.