Poirier N C, Drummond-Webb J J, Hisamochi K, Imamura M, Harrison A M, Mee R B
Center for Pediatric and Congenital Heart Disease and the Department of Pediatric Critical Care, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
J Thorac Cardiovasc Surg. 2000 Nov;120(5):875-84. doi: 10.1067/mtc.2000.109540.
The results of our modification of the stage I Norwood procedure, in which we use only autologous tissue to reconstruct the aortic arch, were reviewed. A high-flow, low-pressure cardiopulmonary bypass protocol (with phenoxybenzamine), before and after a period of deep hypothermic circulatory arrest, was used.
Between 1993 and 1999, 59 patients, aged 1 to 353 days (median 4 days) and weighing 1.7 to 6.8 kg (median 3.2 kg), underwent a modified Norwood procedure. The ascending aortic diameter ranged from 1.5 to 8 mm (median 3 mm). The modified Blalock-Taussig shunt was 3 mm in 21 patients (36%) and 3.5 mm or larger in 38 patients (64%).
Deep hypothermic circulatory arrest and cardiopulmonary bypass times ranged from 15 to 64 minutes (median 37 minutes) and 44 to 144 minutes (median 88 minutes), respectively. Early postoperative survival was 83%. By univariate analysis, early mortality was associated with an ascending aortic diameter of 2.5 mm or less (P =.01). Weight, circulatory arrest and bypass times, diagnosis (hypoplastic left heart syndrome vs variant), shunt size, and date of the procedure did not affect survival. For a median follow-up period of 37 months (range 4-63 months), 42 (61%) patients underwent bidirectional cavopulmonary shunts, 10 (17%) had Fontan operations, and 1 patient underwent transplantation after a bidirectional cavopulmonary shunt. Eight patients subsequently died, for a 1-year actuarial survival of 72% (95% confidence interval: 60%-84%). Neoaortic arch obstruction was corrected in 3 patients (5%).
At intermediate-term follow-up, our modification of the Norwood procedure together with our perioperative strategies has resulted in acceptable outcomes with a low incidence of neoaortic arch obstruction. Patients with a small ascending aortic diameter have emerged as a high-risk group, but a recent technical modification may improve the outlook for these patients.
回顾我们对I期诺伍德手术的改良结果，此改良手术中我们仅使用自体组织重建主动脉弓。在深低温循环停搏前后，采用了高流量、低压体外循环方案（联合使用苯氧苄胺）。
1993年至1999年期间，59例年龄为1至353天（中位数4天）、体重为1.7至6.8千克（中位数3.2千克）的患者接受了改良诺伍德手术。升主动脉直径范围为1.5至8毫米（中位数3毫米）。21例患者（36%）的改良布莱洛克-陶西格分流管为3毫米，38例患者（64%）的分流管为3.5毫米或更大。
深低温循环停搏时间和体外循环时间分别为15至64分钟（中位数37分钟）和44至144分钟（中位数88分钟）。术后早期生存率为83%。单因素分析显示，早期死亡率与升主动脉直径2.5毫米或更小有关（P = 0.01）。体重、循环停搏时间和体外循环时间、诊断（左心发育不全综合征与变异型）、分流管尺寸及手术日期均不影响生存率。中位随访期为37个月（范围4至63个月），42例（61%）患者接受了双向腔肺分流术，10例（17%）进行了Fontan手术，1例患者在双向腔肺分流术后接受了移植。8例患者随后死亡，1年精算生存率为72%（95%置信区间：60% - 84%）。3例患者（5%）纠正了新主动脉弓梗阻。
在中期随访中，我们对诺伍德手术的改良以及围手术期策略带来了可接受的结果，新主动脉弓梗阻发生率较低。升主动脉直径小的患者已成为高危组，但最近的技术改良可能改善这些患者的预后。
