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The infant with single ventricle and excessive

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The infant with single ventricle and excessive pulmonary blood flow: results of a
strategy of pulmonary artery division and shunt
Scott M. Bradley, Janet M. Simsic, Andrew M. Atz and B. Hugh Dorman
Ann Thorac Surg 2002;74:805-810

The online version of this article, along with updated information and services, is located
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The Annals of Thoracic Surgery is the official journal of The Society of Thoracic Surgeons and the
Southern Thoracic Surgical Association. Copyright 2002 by The Society of Thoracic Surgeons.
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The Infant With Single Ventricle and Excessive

Pulmonary Blood Flow: Results of a Strategy of
Pulmonary Artery Division and Shunt
Scott M. Bradley, MD, Janet M. Simsic, MD, Andrew M. Atz, MD, and
B. Hugh Dorman, MD, PhD
Divisions of Cardiothoracic Surgery, Pediatric Cardiology, and Anesthesia, Medical University of South Carolina, Charleston,
South Carolina

Background. The infant with a single ventricle and

excessive pulmonary blood flow requires early protection
of the pulmonary vascular bed to insure suitability for a
subsequent Fontan procedure. The traditional approach,
pulmonary artery banding, has had disappointing results. We have pursued an alternate strategy: division of
the pulmonary artery, and placement of a systemic-topulmonary artery shunt. Potential sites of systemic outflow tract obstruction are simultaneously bypassed, by
either a Damus-Kaye-Stansel, or modified Norwood
procedure.
Methods. From January 1996 to June 2001, 22 infants
were treated by this strategy. Patients with hypoplastic
left heart syndrome were excluded. Median age was 18
days (range 2 days to 6 months). In addition to pulmonary artery division and shunt, 3 of 22 patients underwent a Damus-Kaye-Stansel procedure, and 13 of 22
patients underwent a modified Norwood procedure.
Results. There were no operative deaths, and one late
death. Actuarial survival beyond 30 months was 90%. At
follow-up catheterization in 22 patients, median

transpulmonary gradient was 7 mmHg (range 4 to 18),

and median pulmonary vascular resistance 1.9 Wood
units (range 0.9 to 3.3). Twenty-one patients have undergone a subsequent bidirectional superior cavopulmonary
connection, and 6 a Fontan procedure, with no deaths. No
patient developed subaortic stenosis, or aortic arch obstruction. Neoaortic insufficiency was none or trivial in
12 patients, mild in 3, and moderate in 1.
Conclusions. In patients with a functional single ventricle and excessive pulmonary flow, a strategy of pulmonary artery division and shunt, along with prophylactic
bypass of systemic outflow obstruction, carries low operative and midterm mortality. It provides consistent
protection of the pulmonary vascular bed, avoids subaortic stenosis and aortic arch obstruction, minimizes neoaortic insufficiency, and ensures suitability for progression along a Fontan pathway. These results provide a
comparison for alternate strategies, including pulmonary
artery banding.
(Ann Thorac Surg 2002;74:80510)
2002 by The Society of Thoracic Surgeons

Patients whose pulmonary blood flow is provided by a

systemic-to-pulmonary artery shunt generally demonstrate low pulmonary vascular resistance, and good candidacy for progression along a Fontan pathway [11].
Therefore, in patients with a single ventricle and excessive pulmonary flow, we have pursued a strategy which
includes division of the pulmonary artery, and placement
of a systemic-to-pulmonary artery shunt. Any actual or
potential sites of systemic outflow tract obstruction are
simultaneously bypassed, by either a Damus-KayeStansel, or modified Norwood procedure. The aims of
this report are to assess the results of this strategy on
operative and midterm survival, progression along a
Fontan pathway, pulmonary vascular protection, systemic outflow tract obstruction, and neoaortic insufficiency.

he present management goal for patients with a

functional single ventricle is a successful Fontan
procedure. When surgical palliation is required in early
infancy, it must provide adequate protection of the pulmonary vascular bed, ensuring low pulmonary vascular
resistance [1]. Initial palliation in infants with excessive
pulmonary blood flow has typically been the placement
of a pulmonary artery band. However, results in this
group of patients have often been disappointing [1, 2 8].
There may be difficulty obtaining adequate pulmonary
vascular protection with a pulmonary band placed in
early infancy. Furthermore, patients with excessive pulmonary flow also have a high incidence of systemic
outflow tract obstruction [4, 7, 8]. This places the patient
at risk for ventricular hypertrophy, which is a known risk
factor for a successful Fontan procedure [8 10]. Relieving
systemic outflow tract obstruction further complicates
surgical management.

Presented at the Forty-eighth Annual Meeting of the Southern Thoracic

Surgical Association, San Antonio, TX, Nov 8 10, 2001.
Address reprint requests to Dr Bradley, Division of Cardiothoracic
Surgery, Medical University of South Carolina, 96 Jonathan Lucas St,
Charleston, SC 29425; e-mail: bradlesm@musc.edu.

Material and Methods

Patients
Between January 1996 and June 2001, 22 patients with a
functional single ventricle and excessive pulmonary
blood flow were treated by a strategy of pulmonary artery
division and shunt. This report includes only patients

2002 by The Society of Thoracic Surgeons

Published by Elsevier Science Inc

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0003-4975/02/$22.00
PII S0003-4975(02)03836-5

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Ann Thorac Surg

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Table 1. Patients
Patient

Age
(days)

Diagnosis

Initial Palliation
PA division, shunt
PA division, shunt
PA division, shunt
PA ligation, shunt
PA division, shunt
PA ligation, shunt
DKS
DKS
DKS

Mod Norwood
Mod Norwood

1
2
3
4
5
6
7
8
9

2
22
65
105
140
180
22
41
210

10
11
12
13
14
15
16
17
18
19
20

4
6
7
8
8
8
9
13
13
13
30

Unbalanced AVSD, hypoplastic LV, TAPVC

DORV, mitral stenosis
TGA, VSD, hypoplastic RV
Unbalanced AVSD, hypoplastic RV
Tricuspid atresia
Unbalanced AVSD, hypoplastic LV, TAPVC
Corrected TGA, VSD, tricuspid atresia
DORV, subaortic conus, mitral atresia
DILV, TGA, left AV valve stenosis,
restrictive ASD
Tricuspid atresia, TGA, CoA
Tricuspid atresia, TGA, CoA
DILV, TGA, CoA
DILV, TGA, CoA
DORV, mitral stenosis, CoA
Tricuspid atresia, TGA, CoA
DORV, mitral atresia, CoA
DILV, TGA, CoA
DILV, TGA, CoA
Unbalanced AVSD, hypoplastic LV, CoA
DILV, TGA, CoA

21
22

60
90

Tricuspid atresia, TGA, CoA

DORV, hypoplastic RV, CoA

Mod
Mod
Mod
Mod
Mod
Mod
Mod
Mod
Mod
Mod
Mod

Norwood
Norwood
Norwood
Norwood
Norwood
Norwood
Norwood
Norwood
Norwood
Norwood
Norwood

Associated Procedures

Fontan Stage

Repair TAPVC
Atrial sept
Atrial sept

BSCC
Fontan
BSCC

Atrial sept
Repair TAPVC

BSCC
BSCC
BSCC
Fontan
Fontan

Atrial sept
Atrial sept

Atrial
Atrial
Atrial
Atrial

sept
sept
sept
sept

Atrial sept

Resect AVV tissue,

atrial sept
Atrial sept

Fontan
BSCC
BSCC
BSCC
BSCC
Fontan
Fontan
BSCC
BSCC
Died 1 y after BSCC
BSCC
BSCC
BSCC

ASD, atrial septal defect;

AVSD, atrioventricular septal defect;
AVV, atrioventricular valve;
BSCC, bidirectional superior cavopulmonary
connection;
CoA, aortic coarctation;
DILV, double inlet left ventricle;
DKS, Damus-Kaye-Stansel;
DORV, double outlet right ventricle;
LV, left ventricle;
Mod, modified;
PA, pulmonary artery;
RV, right ventricle;
sept, septectomy;
TAPVC, total anomalous pulmonary
venous connection;
TGA, transposition of the great arteries;
VSD, ventricular septal defect.

who were potential candidates for a pulmonary artery

band; patients with hypoplastic left heart syndrome were
excluded. Early in this period, 2 additional patients
underwent pulmonary artery banding, and are not included in this report. Diagnosis was established by twodimensional echocardiography in all patients (Table 1).
No patient had undergone previous operation, so that
pulmonary artery division and shunt was the initial
palliation in all cases. Three patients were older than 4
months of age at presentation (Table 1). Patients of this
age typically undergo a superior cavopulmonary connection, rather than systemic-to-pulmonary shunt. However,
these 3 patients were judged to be poor candidates for
cavopulmonary connection due to elevated pulmonary
artery pressure (26 to 48 mmHg) and pulmonary vascular
resistance (3.5 to 8.9 Wood units).

Surgical Techniques
All patients underwent interruption of flow through the
pulmonary artery and placement of a systemic-topulmonary artery shunt. The proximal pulmonary artery
was handled by three different approaches, depending
on the potential for systemic outflow tract obstruction. (1)
Six patients were judged to have no potential for development of systemic outflow obstruction. In these 6 patients, the proximal pulmonary artery was divided and
oversewn (4 patients), ligated (1 patient), or ligated by
progressive constriction of an adjustable pulmonary ar-

tery band in the intensive care unit on postoperative day

2 (in 1 patient, whose oxygen saturation was affected by
associated pulmonary parenchymal disease). (2) Three
patients were judged to have the potential for development of subaortic stenosis. In these 3 patients, the proximal pulmonary artery was divided, sewn side-to-side to
the transected ascending aorta, and connected to a patchaugmented distal ascending aorta (Damus-Kaye-Stansel
connection). (3) Thirteen patients had aortic coarctation,
10 with associated aortic arch hypoplasia (defined as an
arch diameter less than the patients weight in kg plus
1 mm). In these 13 patients, the proximal pulmonary
artery was divided and connected to the surgically augmented ascending aorta and aortic arch as a modified
Norwood procedure [12].
Systemic-to-pulmonary artery shunts of polytetrafluoroethylene (Gore-Tex; W.L. Gore and Assoc, Flagstaff,
AZ) were placed from the innominate artery (21 patients)
or ascending aorta (1 patient) to the central pulmonary
artery confluence or origin of the right pulmonary artery.
Shunt diameters were 3.5 mm (12 patients), 4 mm (6
patients), or 5 mm (4 patients). Generally, 4-mm shunts
were used in patients over 3.5 kg, and 5-mm shunts over
4.5 kg. In an effort to avoid shunt thrombosis, all patients
were administered intravenous heparin once operative
bleeding had stopped (target partial thromboplastic time
60 to 80 seconds). When enteric intake resumed, heparin
was converted to aspirin, which was continued indefi-

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BRADLEY ET AL
PULMONARY ARTERY DIVISION AND SHUNT

807

was generated using NCSS 2000 for Windows (Number

Cruncher Statistics Systems, Kaysville, UT). All patients
were followed within the Pediatric Heart Center of South
Carolina, a pediatric cardiology network providing coordinated congenital cardiac care to the state.

Results
Early Outcomes

Fig 1. Actuarial survival in 22 patients with a functional single ventricle and excessive pulmonary flow.

nitely. Associated procedures performed were atrial septectomy in 12 patients, repair of total anomalous pulmonary venous connection in 2, and resection of accessory
atrioventricular valve tissue in 1 (Table 1). Cardiopulmonary bypass, cardioplegic myocardial arrest, and periods
of circulatory arrest were used in 21 of the 22 operations.
The average cardiopulmonary bypass time (mean SD)
was 164 52 minutes, cross-clamp time 46 17 minutes,
and circulatory arrest time 32 21 minutes.
Subsequent bidirectional superior cavopulmonary
connection (BSCC) consisted of a bidirectional Glenn
shunt in 16 patients, hemi-Fontan procedure in 4, and
Kawashima procedure in 1. Additional procedures at the
time of BSCC were connection of a left superior vena
cava to the left pulmonary artery (left bidirectional Glenn
shunt) in 5 patients, atrioventricular valve repair in 2,
reimplantation of an anomalously draining right upper
pulmonary vein in 1, and patch closure of an insufficient
left atrioventricular valve in 1. Completion Fontan procedures were fenestrated intra-atrial lateral tunnel connections in 4 patients, and extracardiac conduits in 2.

Data Collection/Follow-Up
All records were retrospectively reviewed. Cardiac catheterization was performed before each BSCC, and again
before each Fontan procedure. Subaortic stenosis or
aortic arch obstruction during follow-up were defined as
a gradient of 20 mmHg or greater by echocardiogram or
catheterization. Neoaortic insufficiency and atrioventricular valve regurgitation were qualitatively graded by
echocardiogram on a scale from 0 (none) to 4 (severe).
Ventricular function was qualitatively graded by echocardiogram and angiography. Actuarial survival curve

The median age of the 22 patients at operation was 18

days (range 2 days to 6 months). There were no operative
deaths. One patient required shunt revision for distal
stenosis 4 days following a modified Norwood procedure.
There were no instances of shunt thrombosis. Other
complications included seizures in 1 patient, subglottic
stenosis requiring laser therapy in 1 patient, and sinus
node dysfunction requiring pacemaker placement in 1
patient. During the same hospitalization, 2 patients underwent gastrostomy tube placement for inadequate oral
feeding, and 1 patient underwent a prophylactic Ladds
procedure for intestinal malrotation. The median hospital stay was 16 days, with a range of 6 to 86 days.
Follow-up was complete in all patients at a median of 29
months (range 7 months to 6 years). There was a single
late death, at age 2.5 years, 1 year after BSCC, due to
pneumonia. Actuarial survival beyond 30 months was
90% (Fig 1).

Fontan Pathway
Twenty-one of the 22 patients have undergone a subsequent BSCC at a median age of 8 months (range 4 to 15
months). Six patients have undergone a completion Fontan procedure at a median age of 29 months (range 23 to
44 months). There were no deaths or operative failures at
either stage.

Pulmonary Vascular Protection

All patients have undergone cardiac catheterization in
preparation for BSCC (Table 2). A single patient had
elevated pulmonary pressure (32 mmHg) and transpulmonary gradient (18 mmHg). This patient, with unbalanced atrioventricular septal defect and trisomy 21, presented late. He underwent initial palliation at 3.4 months
of age, with pulmonary artery ligation and placement of
a 5-mm shunt. At subsequent catheterization, his pulmonary-to-systemic flow ratio (Qp:Qs) was 2.6, so that his
calculated pulmonary vascular resistance was low (2.2
Wood units), in spite of elevated pulmonary pressure. He
has not yet undergone BSCC.
Nine patients have undergone catheterization in preparation for a completion Fontan procedure (Table 2).

Table 2. Follow-Up Cardiac Catheterizationa

Variable

Patients

Pulmonary Artery
Pressure (mmHg)

Transpulmonary
Gradient
(mmHg)

Pulmonary Vascular
Resistance (Wood units)

22
9

15 (10 32)
10 (6 17)

7 (4 18)
4 (3 4)

1.9 (0.9 3.3)

1.4 (0.9 2.2)

Pre-BSCC
Pre-Fontan
a

Values are median (range).

BSCC bidirectional superior cavopulmonary connection.

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Transpulmonary gradient and pulmonary vascular resistance were low in all.

Systemic Outflow Tract Obstruction; Valvular

Insufficiency
No patient developed either subaortic stenosis or aortic
arch obstruction, as assessed by either echocardiography
or catheterization. At most recent follow-up, atrioventricular valve insufficiency was grade 0 to 1 (none to trivial)
in 9 patients, grade 2 (mild) in 12 patients, and grade 3
(moderate) in 1 patient. Ventricular function was normal
in 19, and mildly depressed in 3 patients. In the 16
patients who underwent either a Damus-Kaye-Stansel or
modified Norwood procedure, function of the pulmonary
(neoaortic) valve was assessed during follow-up by echocardiography. The 3 patients who had a Damus-KayeStansel procedure had no neoaortic insufficiency. The 13
Norwood patients had grade 0 to 1 (none to trivial) in 9
patients, grade 2 (mild) in 3 patients, and grade 3 (moderate) in 1 patient.

Comment
Patients with a functional single ventricle and excessive
pulmonary blood flow continue to present a surgical
challenge. The traditional approach to such patients has
been a pulmonary artery band. Associated coarctation
has been treated by repair via a left thoracotomy. This
approach has the advantages of avoiding cardiopulmonary bypass and circulatory arrest. However, the early
results of this approach were not optimal, with significant
operative and late mortality, and poor candidacy for a
Fontan operation [1, 4 6, 13]. For example, in patients
with double-inlet ventricle, Franklin and colleagues
found that among 35 patients treated with a pulmonary
band, survival was 77% at 1 year and 45% at 5 years [5].
Suitability for a Fontan operation was 14 of 33 patients
(42%) [6]. Among 18 patients treated with a pulmonary
band and coarctation repair, survival was 44% at 1 year
and 22% at 5 years [5]. Fontan suitability was 1 of 12
patients (8%) [6].
The use of a pulmonary band in patients with a
functional single ventricle and excessive pulmonary flow
can be complicated by the occurrence of subaortic stenosis. Freedom and coworkers observed the development
of subaortic stenosis in 72% of patients with a univentricular heart treated with a pulmonary band [2]. Subaortic stenosis can result in ventricular hypertrophy, which
is a risk factor for a Fontan operation [9, 10]. The factors
leading to subaortic stenosis have been extensively and
expertly discussed [3, 8]. Morphologic factors include
origin of the aorta from an outlet chamber which is
supplied by a bulboventricular foramen or ventricular
septal defect. Matitiau and associates further refined this
observation by determining that a bulboventricular foramen size of less than 2 cm2/m2 is associated with the later
development of subaortic stenosis [14]. The presence of
aortic arch obstruction is also associated with both a
small bulboventricular foramen and the subsequent development of subaortic stenosis [14]. Several groups have
reported that subaortic stenosis developed in 100% of

Ann Thorac Surg

2002;74:80510

survivors of palliation by a pulmonary band and aortic

arch repair [4, 7, 13].
More recent series have reported improved results of
pulmonary artery banding in patients with a functional
single ventricle [1518]. The approach taken in these
series has been to leave the band in place for a short time,
and carefully follow the patients for the development of
subaortic stenosis. The operative mortality of banding,
with or without concomitant arch repair, was low, ranging from 0% to 8% [16 18]. However, subaortic stenosis
occurred frequently, being seen in 64% to 100% of patients at a median interval of 3 to 8 months [15, 17], and
within 1 month in several cases [16 18]. Thus, frequent
early reoperation for subaortic stenosis remains a drawback to pulmonary banding.
The alternative of prophylactically bypassing the subaortic area in patients at risk for subaortic stenosis has
been advocated for some time [1, 19 21]. By avoiding
subaortic stenosis, rather than treating it once it has
occurred, this approach has the potential of avoiding
ventricular hypertrophy, thereby improving suitability
for a Fontan procedure [9, 10]. The main drawback to this
approach is a complex operation utilizing cardiopulmonary bypass, and potentially circulatory arrest, in a neonate. Several groups pioneered this approach in the late
1980s and early 1990s [1, 14, 19, 20]. More recently,
operative mortalities below 20% have been reported for
Norwood procedures carried out for defects other than
hypoplastic left heart syndrome [2225]. Mosca and associates reported the use of a modified Norwood procedure in 38 patients with a single left ventricle and
ventriculoarterial discordance [12]. In this fairly uniform
group, there were only three early deaths (8%), and five
late deaths (overall mortality 21%). Our results further
support the use of pulmonary artery division, shunt, and
prophylactic bypass of systemic outflow tract obstruction
as a management strategy.
In patients who are not at risk for subaortic stenosis,
the distinction between the current strategy and pulmonary artery banding is less clear. Placement of a pulmonary band is a relatively simple operation, which can
be performed without cardiopulmonary bypass. The use
of a pulmonary band in this situation has been suggested
by groups which advocate a Damus-Kaye-Stansel or
Norwood approach in patients at risk for subaortic stenosis [25, 26]. However, there is little data in the literature
on the results of pulmonary banding in patients without
systemic outflow obstruction [1, 7]. There are also several
arguments favoring pulmonary artery division and shunt
over a pulmonary band. In the operating room, it can be
difficult to predict the eventual effectiveness of a pulmonary band. Following banding, the pulmonary artery can
remodel, resulting in a lower gradient than intended. A
band is adjusted under nonphysiologic conditions, including general anesthesia, positive pressure ventilation,
and an open chest. Under physiologic conditions several
days later, the band gradient may well be different [27].
Furthermore, when a band is placed in a neonate, pulmonary vascular resistance can be expected to fall over
the following days or weeks, also affecting the band

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BRADLEY ET AL
PULMONARY ARTERY DIVISION AND SHUNT

gradient. In contrast, a shunt has a uniform diameter, and

is not generally adjusted in the operating room. A great
deal of experience with the Norwood operation is now
available to guide the selection of shunt size in neonates.
Follow-up catheterization in a large number of patients
with shunts placed in the neonatal period has confirmed
consistent pulmonary vascular protection [11]. Of interest, in the Boston Childrens Hospital experience, 17% of
patients who had a pulmonary band required subsequent division of the pulmonary artery and substitution
of a shunt [1]. Pulmonary banding may well be considered in selected patients. However, we have been
pleased with the results of an initial palliation which
results in a shunt as the sole source of pulmonary blood
flow.
Neoaortic insufficiency is a potential concern following
any operation which places the pulmonary valve in the
aortic position [28]. Significant insufficiency has been
unusual following a primary Damus-Kaye-Stansel or
modified Norwood procedure [12, 22, 25, 28]. Our results
are in agreement, with 1 of 16 patients having more than
mild neoaortic insufficiency during follow-up. Several
groups have examined neoaortic valve function in patients who have had a Damus-Kaye-Stansel procedure
after a previous pulmonary band [18, 28, 29]. Jenkins and
colleagues observed moderate insufficiency in 2 of 13
patients; Amin and coworkers found moderate insufficiency in 1 of 15 patients; Daenen and associates noted
more than mild insufficiency in 0 of 12 patients [18, 28,
29]. Significant pulmonary valve damage by a band is
thus unusual. However, there have been anecdotal reports of the pulmonary valve being so damaged by a
band, that a planned Damus-Kaye-Stansel procedure
had to be aborted [26].
There are several other potential disadvantages to a
strategy of pulmonary artery division and shunt placement. Some of these relate to the shunt, and include
shunt thrombosis, pulmonary overcirculation with systemic hypoperfusion, low diastolic blood pressure with
resulting coronary ischemia, and pulmonary artery distortion. The patients in the current report had no episodes of shunt thrombosis, which may have been due to
the postoperative use of intravenous heparin, followed
by conversion to aspirin. Pulmonary overcirculation and
low diastolic pressure are unusual with proper shunt
sizing, and generally respond to appropriate ventilator
management and inotropic support. Pulmonary artery
distortion in this experience was minor, and well dealt
with at subsequent BSCC. Finally, most of the modified
Norwood operations in this report were performed using
circulatory arrest, which may carry a risk of neurologic
damage. Late in this experience, we adopted regional low
flow perfusion via the innominate artery to avoid circulatory arrest. Whether this will result in improved neurologic outcomes is currently unknown.
To summarize, in infants with a functional single
ventricle and excessive pulmonary flow, we have utilized
a strategy of pulmonary artery division, shunt placement,
and prophylactic bypass of systemic outflow tract obstruction. This strategy was carried out with no operative

809

deaths, and 90% survival beyond 30 months. Follow-up

cardiac catheterization has demonstrated consistent protection of the pulmonary vascular bed. No patient has
developed subaortic stenosis or aortic arch obstruction.
Function of the pulmonary valve in the neoaortic position
has been good, with moderate neoaortic insufficiency in 1
patient. Twenty-one patients have progressed to BSCC,
and 6 to a completion Fontan procedure, without operative mortality or failure. The results of this strategy
compare favorably with those of other approaches, such
as pulmonary banding.

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DISCUSSION
DR JOHN H. CALHOON (San Antonio, TX): Dr Bradley, what a
beautifully illustrated series and nice presentation. I have one
question: How do you decide what anatomic substrate should go
to each of your three operative strategies, whether you oversew
the pulmonary artery, perform a Damus-Kaye-Stansel, or utilize
a Norwood? What anatomic things do you see that have given
you the ability to predict which infants will do best with those
and to have avoided the problems of subaortic obstruction or
arch obstruction with a Damus-Kaye?
Thank you again for a nice series and this information.
DR BRADLEY: Thank you very much for your comments. We
basically start by looking at the aortic arch. Any patient who has
coarctation of the aorta, with or without hypoplasia of the aortic
arch, undergoes a modified Norwood procedure. In the remaining patients, we look at the internal anatomy of the heart. Any
patient who has origination of the aorta from an outlet chamber,
in other words, a chamber served not by an atrioventricular
valve, but instead by a bulboventricular foramen or a ventricular
septal defect, undergoes a Damus-Kaye-Stansel procedure. One
other patient in our series, with double-outlet right-ventricle
and mitral atresia, had subaortic conal tissue that was judged to
be potentially restrictive, and also underwent a Damus-KayeStansel procedure. The remaining patients have been shown in
a number of series to be at low risk for the development of
subaortic stenosis, and they undergo simple division of the main
pulmonary artery and shunt placement.
DR ROSS M. UNGERLEIDER (Portland, OR): Scott, thanks for
sharing that. I think you have presented three distinctly different
groups of patients, and I would have no argument personally
with the strategy you have employed for the groups that need
either aortic arch reconstruction with a modified Norwood or a
Damus-Kaye-Stansel for the prevention of subsequent subaortic
obstruction.

I am most interested in your first set of patients, the 6 patients

who received oversewing of the pulmonary artery and a shunt
for what was simply excessive pulmonary blood flow without the
risk of aortic obstruction. Were you doing these procedures on
bypass or off bypass? If you were doing them on bypass, have
you compared your bypass operation of oversewing of the
pulmonary artery and a shunt to patients who simply receive a
pulmonary artery band with respect to outcome and other
perioperative morbidity factors? My point is, I think, that that
subset of patients might do pretty well with simply a band done
off bypass, unless you are doing your initial operation off bypass.
Thank you.
DR BRADLEY: Thank you for your comments; you have hit on
the potentially controversial issue in this talk. Cardiopulmonary
bypass was utilized in 5 out of the 6 patients who were treated by
pulmonary artery division and shunt placement. Bypass was
used in those 5 cases because of associated procedures: atrial
septectomy in 3, and repair of total anomalous pulmonary
venous return in 2. In the absence of associated procedures,
pulmonary artery division and shunt placement can be carried
out without cardiopulmonary bypass. Whether there is an important difference between a pulmonary band and the approach
that I have described in that particular set of 6 patients is a good
question. For a variety of reasons, which are detailed in the
paper, it can be difficult to accurately predict the eventual
effectiveness of a band placed in a neonate. In contrast, a shunt,
once properly placed, provides a uniform and controlled source
of pulmonary flow. Our bias has been that the most consistent
way to attain protection of the pulmonary vascular bed is to
come out of the operating room with a shunt providing the only
source of pulmonary blood flow. However, the point of this is
not to say that pulmonary bands are never useful. It is always
important to maintain flexibility in approach, and we present
these results for potential comparisons.

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The infant with single ventricle and excessive pulmonary blood flow: results of a
strategy of pulmonary artery division and shunt
Scott M. Bradley, Janet M. Simsic, Andrew M. Atz and B. Hugh Dorman
Ann Thorac Surg 2002;74:805-810

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