ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Peter C. Laussen
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Cua, C. L.
Right arrow Articles by Feltes, T. F.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Cua, C. L.
Right arrow Articles by Feltes, T. F.
Related Collections
Right arrow Congenital - cyanotic

Ann Thorac Surg 2005;80:44-49
© 2005 The Society of Thoracic Surgeons

Original article: Cardiovascular

Improved Interstage Mortality With the Modified Norwood Procedure: A Meta-Analysis

Clifford L. Cua, MDa,*, Ravi R. Thiagarajan, MDb, Roozbeh Taeed, MDa, Timothy M. Hoffman, MDa, Lillian Lai, MDb, John Hayes, PhDa, Peter C. Laussen, MBBSb, Timothy F. Feltes, MDa

a Department of Pediatrics, Division of Pediatric Cardiology, Columbus Children’s Hospital, Columbus, Ohio
b Department of Cardiology, Children’s Hospital Boston, Boston, Massachusetts

Accepted for publication January 20, 2005.

* Address reprint requests to Dr Cua, Department of Pediatrics, Division of Pediatric Cardiology, Columbus Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205-2696 (Email: cuac{at}pediatrics.ohio-state.edu).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
BACKGROUND: Modification of the Norwood procedure has been reported to improve immediate postoperative mortality compared with the classic Norwood. Interstage mortality has not been shown to be improved with the modified Norwood probably because of the small number of patients from each institution. The goal of this study was to determine if meta-analysis would provide sufficient data to prove statistical difference in interstage mortality for the modified Norwood procedure.

METHODS: PubMed was searched using six different terms individually for articles from January 2003 to October 2004. Manuscripts that compared the classic to modified Norwood were reviewed. Mantel-Haenszel analysis was used to evaluate the relationship between treatment method and mortality stratified across hospitals. The Breslow-Day procedure tested homogeneity of odds ratio across hospitals. Separate analyses were performed for inpatient and interstage periods.

RESULTS: A total of 4,545 citations was screened. Five manuscripts met the criteria. Seventy-two patients undergoing classic Norwood and 84 patients undergoing modified Norwood survived to initial hospital discharge. The Breslow-Day statistic supported homogeneity of odds ratios for survival across hospitals ({chi}2 = 2.09, df = 4, p = 0.72). Odds of interstage death was 11.6 times greater (2.2 to 62.1, 95% CI) for the classic Norwood compared with the modified Norwood procedure. This difference was statistically significant by the Mantel-Haenszel {chi}2 (11.0, p = 0.001). The Breslow-Day statistic supported homogeneity of the odds ratios across hospitals ({chi}2 = 3.1, df = 4, p = 0.53).

CONCLUSIONS: The modified Norwood procedure has a significantly lower interstage mortality compared with the classic Norwood procedure. A large randomized study is needed to determine whether these results remain consistent.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Mortality and morbidity for patients with hypoplastic left heart syndrome (HLHS) has improved as more knowledge is obtained for treatment of this defect. Despite improved results with the Norwood procedure using a modified Blalock-Taussig shunt (NW-BT), mortality still remains high with rates varying from 10% to 40% [1–10]. One significant problem that still remains prevalent for patients with HLHS undergoing the NW-BT palliation is the mortality rate between the first (Norwood) and second (bidirectional Glenn) stage surgical procedures. Despite improvements in medical and surgical care, reports of interstage mortality still range from 5% to 20% [1, 4, 7, 9, 11–15]. Numerous risk factors exist for mortality and include anatomic variant, age, and size of the patient, preoperative and postoperative management, and surgical experience [6, 8, 16–21]. At least one pathology study has implicated coronary artery anatomical abnormalities as one major cause of death [22]. Some institutions have been able to significantly reduce this interstage mortality with close follow-up [12, 23].

A recent modification of the Norwood procedure consisting of a right ventricle to pulmonary artery conduit (NW-RVPA) to supply pulmonary blood flow instead of the modified Blalock-Taussig shunt has been reported by various institutions to improve early mortality [1–3, 5, 11, 24–26]. The theory behind this modification is that coronary artery blood supply will be preserved owing to higher diastolic blood pressure that occurs in the NW-RVPA compared with the NW-BT procedure and thus will result in improved early mortality. While these early reports are favorable for the NW-RVPA procedure, the midterm and long-term results are still unknown. Theoretically, if a major cause of interstage deaths was due to poor myocardial perfusion from abnormal coronary anatomy, then the higher diastolic blood pressures in patients undergoing the NW-RVPA procedure should improve coronary perfusion and therefore reduce interstage mortality. Unfortunately, the numbers of patients in each of the institutional experiences comparing the NW-BT to NW-RVPA procedures have been too small to show if there were significant differences for interstage mortality between the two groups.

The goal of this study was to determine if there was a significant difference in interstage mortality, defined as time from hospital discharge after stage I procedure to completion of stage II, between patients undergoing the NW-BT versus the NW-RVPA procedure. Meta-analysis was used to achieve the patient size to assess a statistically significant difference.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
This study was approved by the Investigational Review Board of Columbus Children’s Hospital. Studies included in the analysis were identified by searching PubMed (National Library of Medicine) from January 2003 to October 2004. By limiting the data collected to the most recent publications, we hoped to limit the heterogeneity of the management styles to the "current era." Terms used to search for appropriate articles were performed individually to obtain the largest possible list and included "Norwood," "conduit," "hypoplastic left heart," "single ventricle," "shunt," and "Sano." The manuscripts were reviewed to determine whether they met selection criteria.

Manuscripts were selected if they met all of the following requirements: compared a cohort of patients undergoing the NW-BT procedure to the NW-RVPA procedure for palliation of single ventricle physiology; documented baseline demographics such as number of patients in each group; age and weight at time of surgery; documented hospital mortality; and documented interstage mortality. Studies without the above data were excluded. In addition to the data above, anatomical diagnosis, ascending aorta diameter, sex, shunt/conduit placed, cardiopulmonary bypass time, presence of a restrictive atrial communication, length of intensive care stay, and number of patients completing a stage II procedure were also recorded if available.

A Mantel-Haenszel analysis was used to evaluate the relationship between treatment method and mortality stratified across hospitals. The Mantel-Haenszel procedure provides a common odds ratio estimate and confidence interval (CI) showing the risk of death using the NW-BT procedure relative to the NW-RVPA procedure. Separate analyses were performed for inpatient and interstage periods. The Breslow-Day procedure tested the homogeneity (consistency) of the odds ratio across hospitals.

The primary analysis used intention to treat to classify patients into treatment groups. A secondary analysis was conducted to adjust for 4 patients who were reassigned to the NW-BT group after an NW-RVPA procedure and 7 patients who had been discharged, but had not yet had their bidirectional Glenn procedure.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
Searching PubMed from January 2003 to October 2004, 174 titles were found when "Norwood" was entered, 785 titles for "conduit," 166 titles for "hypoplastic left heart," 544 titles for "single ventricle," 2,180 titles for "shunt," and 696 titles for "Sano." After reviewing the data, a total of five manuscripts met the inclusion criteria stated above. These manuscripts were written by authors Azakie and associates [2], Bradley and associates [1], Mair and colleagues [5], Pizarro and coworkers [4], and Mahle and colleagues [11].

The operative time period for patients described in the papers ranged from October 1999 to November 2003. Each procedure, NW-BT and NW-RVPA, had a total of 93 patients in their respective cohort. Baseline demographics qualitatively showed minimal differences in age at surgery, weight at surgery, or ascending aorta diameter (Table 1). Diagnosis, shunt or conduit size used, presence of a restrictive atrial communication, cardiopulmonary bypass duration, and intensive care lengths of stay were also recorded if available (Table 2). Statistical analysis was not performed on these data to determine homogeneity between the different manuscript demographics because insufficient information was available for comparison.


View this table:
[in this window]
[in a new window]
  		Table 1. Demographics
 

View this table:
[in this window]
[in a new window]
  		Table 2. Hospital Data
 
There was a total of 21 hospital deaths in the NW-BT group and 9 deaths in the NW-RVPA group, for an overall mortality of 22.6% and 9.7%, respectively (Table 2); therefore, 72 NW-BT patients and 84 NW-RVPA patients were alive at time of hospital discharge (Table 3). Bradley and coworkers [1] reported that 2 patients had the NW-RVPA procedure converted to a NW-BT "on the second day after surgery because of hypoxemia." Mahle and associates [11] also reported cross-over of the NW-RVPA to a NW-BT in 2 patients. One patient had a pseudoaneurysm at the site of the conduit during the initial hospitalization and "underwent resection of the pseudoaneurysm and conversion to a modified Blalock-Taussig shunt." The other patient had elevated pulmonary artery pressures on follow-up and "in an attempt to reduce pulmonary artery pressure," the conduit was changed to a 3.5-mm right modified Blalock-Taussig shunt. These 4 patients could either be considered failed NW-RVPA patients, but who did not die, or thought of as cross-over patients, making the total 76 NW-BT and 80 NW-RVPA alive at time of hospital discharge (Table 3).


View this table:
[in this window]
[in a new window]
  		Table 3. Interstage Mortality
 
Based on intention to treat analysis, the risk of dying before discharge after initial procedure was 2.62 times greater (1.12 to 6.14, 95% CI) for the NW-BT procedure relative to the NW-RVPA. This difference was significant by the Mantel-Haenszel {chi}2 (4.42, p = 0.04). The Breslow-Day statistic supported homogeneity of the odds ratios for improved survival after NW-RVPA compared with NW-BT across the institutions ({chi}2 = 2.09, df = 4, p = 0.72).

Overall, interstage mortality was 19.4% (14 of 72) for the NW-BT procedure and 2.4% (2 of 84) for the NW-RVPA procedure. The risk for interstage death was 11.6 (2.2 to 62.1, 95% CI) times greater for the NW-BT procedure relative to the NW-RVPA. This difference was significant by the Mantel-Haenszel {chi}2 (11.0, p = 0.001) indicating that patients undergoing the NW-BT procedure had increased risk of death after discharge from the hospital while awaiting the bidirectional Glenn procedure. The Breslow-Day statistic supported homogeneity of the odds ratios across hospitals ({chi}2 = 3.1, df = 4, p = 0.53). Qualitatively, the age at which stage II was performed on both cohorts were similar within institutions, but varied among institutions (Table 3).

Sensitivity of the findings was tested by eliminating the 7 NW-RVPA patients who had not yet undergone the second procedure, 4 patients from Azakie and colleagues [2] and 3 patients from Bradley and associates [1]. Furthermore, 4 subjects who had the NW-BT procedure after the NW-RVPA procedure were also crossed over to that group, 2 patients from Bradley and associates [1] and 2 patients from Mahle and colleagues [11]. The results were essentially the same. When adjusting for the 4 patients who crossed over from the NW-RVPA to NW-BT group and excluding the 7 patients in the NW-RVPA group that had not completed the stage II procedure at time of publication, interstage death was 18.4% (14 of 76) for the NW-BT and 2.7% (2 of 73) for the NW-RVPA group. The risk of death was 8.8 (1.64 to 47.3, 95% CI) times greater for the NW-BT procedure relative to the NW-RVPA. This difference was significant by the Mantel-Haenszel {chi}2 (6.5, p = 0.011). The Breslow-Day statistic supported homogeneity of the odds ratios for survival postdischarge after NW-RVPA compared with NW-BT across the institutions ({chi}2 = 3.36, df = 4, p = 0.50). Mahle and coworkers [11] described 27 patients discharged from the hospital after initial surgery with 4 interstage deaths. Twenty-two of the possible 23 patients had subsequently undergone the second stage procedure. This 1 patient was not included in adjusted analysis because of uncertainty which procedure was performed. Inclusion or exclusion of this patient did not change significance.


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
Since Norwood first described a procedure to palliate HLHS [27], numerous advances have occurred that have improved overall survival for patients with this congenital heart defect [9, 24, 28–33]. Following the most recent modification of the Norwood procedure, institutions have reported improved first stage mortality [1–5, 11, 25, 26, 34, 35]; however, no study concerning the NW-RVPA procedure has demonstrated statistically significant improved interstage mortality compared with the NW-BT procedure [1, 2, 4, 7, 9, 11–15]. These results may be because the number of patients in each of the reports has been too small to have sufficient power to reach significance. By performing a meta-analysis of available data, this study reveals a significant decrease in interstage mortality for the NW-RVPA procedure compared with the NW-BT operation. Patients in the manuscripts selected for purposes of this study had qualitatively similar weights, age at operation, and ascending aorta diameter. Furthermore, there was a homogeneity in the odds ratio for mortality across the hospitals that indirectly argues for the idea that one study did not have undue influence on the total analysis and that there was similarity among patient populations.

Numerous reasons have been documented or theorized to be the etiology of interstage mortality; these include decreased coronary perfusion, shunt obstruction, arrhythmias, right ventricular failure, residual arch lesions, acute intercurrent illness, or atrioventricular valve regurgitation. Unexpected death also continues to be a significant documented cause of interstage mortality [12, 14, 22]. Assuming that residual arch lesions, intercurrent illness, and atrioventricular regurgitation would be similar between the two groups despite the different time periods examined, possible reasons for the improved mortality in the NW-RVPA group could be improved coronary perfusion, decreased risk for shunt obstruction, decreased risk for arrhythmias, or nonspecific factors that may be characterized as "experience" with treatment of patients with HLHS.

Hypothetically, the larger conduits used for the NW-RVPA procedure would be less likely to occlude compared with the smaller shunts used for the NW-BT operation. In the papers analyzed, shunt size ranged from 2.5 to 4.0 mm, whereas the conduit sizes were from 4.0 to 6.0 mm. Decreased risk for arrhythmias may also be a possibility for improved mortality in the NW-RVPA group because of improved coronary perfusion; however, this must be weighed against the risk of ventricular arrhythmias due to the right ventriculotomy in the NW-RVPA procedure. Overall improvement in quality of care for patients with HLHS cannot be excluded as a possible reason for the improved mortality, especially since the two cohorts were from different time periods, albeit relatively close to one another. Markedly improved interstage mortality has been reported for the NW-BT group with strict follow-up [12], but there was no evidence that such a protocol was initiated in the five institutions analyzed to account for the differences in mortality.

Another theoretical reason for improved interstage survival for the NW-RVPA procedure could be the higher diastolic blood pressure because of lack of "run off" in the shunt compared with the NW-BT procedure, and therefore improved coronary perfusion. Postmortem studies of patients with HLHS undergoing the NW-BT procedure have attributed the majority of deaths to coronary abnormalities [22]. Furthermore, it has been shown that infants with HLHS have less perfusion and oxygen delivery to the systemic ventricle after the NW-BT procedure compared with infants with fully corrected congenital heart disease [36]. The higher diastolic blood pressures may help overcome the inherent difficulty of supplying coronary perfusion through a hypoplastic ascending aorta despite arch augmentation. One study showed improved interstage mortality with strict follow-up and early intervention if there was systemic desaturation or poor weight gain [12]. One could hypothesize that if the patients who underwent the NW-BT procedure were exposed constantly to decreased coronary perfusion, their cardiac output would eventually decrease. Decreased cardiac output would decrease mixed venous saturation and therefore systemic saturation and decreased cardiac output would also explain the poor weight gain.

Limitations of this study include all the limitations of the reviewed manuscripts including the inherent shortcomings of a meta-analysis. Etiologies of interstage deaths were not documented, so we can only speculate on causes. Two studies did not record time to stage II; therefore, we cannot rule out the possibility that NW-BT patients may have had "more time to die" if they had their stage II performed later compared with the NW-RVPA patients. None of the studies were randomized prospective trials comparing the two different procedures. In general, the two cohorts of patients in the different studies had surgery during different time periods as institutions transitioned from NW-BT procedure to the NW-RVPA procedure. Advances in preoperative, operative, and postoperative care cannot be ruled out as a possible reason for improvement in interstage deaths.

In conclusion, this study revealed that there was a significant difference in interstage mortality between the NW-BT versus the NW-RVPA operation after review of the available literature. Midterm and long-term results for this procedure are still unknown, and the concern for ventricular dysfunction and arrhythmia due to the right ventriculotomy will likely be unanswered in the immediate future; however, the decreased surgical and interstage mortality rate makes this procedure an attractive option. Only a large, multicenter, randomized, controlled trial will be able to truly show whether there are any advantages of one procedure over the other.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Bradley SM, Simsic JM, McQuinn TC, Habib DM, Shirali GS, Atz AM. Hemodynamic status after the Norwood procedurea comparison of right ventricle-to-pulmonary artery connection versus modified Blalock-Taussig shunt. Ann Thorac Surg 2004;78:933-941.[Abstract/Free Full Text]
  2. Azakie A, Martinez D, Sapru A, Fineman J, Teitel D, Karl TR. Impact of right ventricle to pulmonary artery conduit on outcome of the modified Norwood procedure Ann Thorac Surg 2004;77:1727-1733.[Abstract/Free Full Text]
  3. Sano S, Ishino K, Kawada M, et al. Right ventricle-pulmonary artery shunt in first-stage palliation of hypoplastic left heart syndrome J Thorac Cardiovasc Surg 2003;126:504-510.[Abstract/Free Full Text]
  4. Pizarro C, Malec E, Maher KO, et al. Right ventricle to pulmonary artery conduit improves outcome after stage I Norwood for hypoplastic left heart syndrome Circulation 2003;108(Suppl 1):II155-II160.
  5. Mair R, Tulzer G, Sames E, et al. Right ventricular to pulmonary artery conduit instead of modified Blalock-Taussig shunt improves postoperative hemodynamics in newborns after the Norwood operation J Thorac Cardiovasc Surg 2003;126:1378-1384.[Abstract/Free Full Text]
  6. Ashburn DA, McCrindle BW, Tchervenkov CI, et al. Outcomes after the Norwood operation in neonates with critical aortic stenosis or aortic valve atresia J Thorac Cardiovasc Surg 2003;125:1070-1082.[Abstract/Free Full Text]
  7. Tweddell JS, Hoffman GM, Mussatto KA, et al. Improved survival of patients undergoing palliation of hypoplastic left heart syndromelessons learned from 115 consecutive patients. Circulation 2002;106(12 Suppl 1):I82-I89.
  8. Lofland GK, McCrindle BW, Williams WG, et al. Critical aortic stenosis in the neonate: a multi-institutional study of management, outcomes, and risk factors. Congenital Heart Surgeons Society J Thorac Cardiovasc Surg 2001;121:10-27.
  9. Azakie T, Merklinger SL, McCrindle BW, et al. Evolving strategies and improving outcomes of the modified norwood procedurea 10-year single-institution experience. Ann Thorac Surg 2001;72:1349-1353.[Abstract/Free Full Text]
  10. Andrews R, Tulloh R, Sharland G, et al. Outcome of staged reconstructive surgery for hypoplastic left heart syndrome following antenatal diagnosis Arch Dis Child 2001;85:474-477.[Abstract/Free Full Text]
  11. Mahle WT, Cuadrado AR, Tam VK. Early experience with a modified Norwood procedure using right ventricle to pulmonary artery conduit Ann Thorac Surg 2003;76:1084-1089.[Abstract/Free Full Text]
  12. Ghanayem NS, Hoffman GM, Mussatto KA, et al. Home surveillance program prevents interstage mortality after the Norwood procedure J Thorac Cardiovasc Surg 2003;126:1367-1377.[Abstract/Free Full Text]
  13. Forbess JM. Pre-stage II mortality after the Norwood operationaddressing the next challenge. J Thorac Cardiovasc Surg 2003;126:1257-1258.[Free Full Text]
  14. Mahle WT, Spray TL, Gaynor JW, Clark III BJ. Unexpected death after reconstructive surgery for hypoplastic left heart syndrome Ann Thorac Surg 2001;71:61-65.[Abstract/Free Full Text]
  15. Mahle WT, Spray TL, Wernovsky G, Gaynor JW, Clark III BJ. Survival after reconstructive surgery for hypoplastic left heart syndromea 15-year experience from a single institution. Circulation 2000;102(19 Suppl 3):III136-III141.
  16. Fountain-Dommer RR, Bradley SM, Atz AM, Stroud MR, Forbus GA, Shirali GS. Outcome following, and impact of, prenatal identification of the candidates for the Norwood procedure Cardiol Young 2004;14:32-38.
  17. Pizarro C, Davis DA, Galantowicz ME, Munro H, Gidding SS, Norwood WI. Stage I palliation for hypoplastic left heart syndrome in low birth weight neonatescan we justify it?. Eur J Cardiothorac Surg 2002;21:716-720.[Abstract/Free Full Text]
  18. Gaynor JW, Mahle WT, Cohen MI, et al. Risk factors for mortality after the Norwood procedure Eur J Cardiothorac Surg 2002;22:82-89.[Abstract/Free Full Text]
  19. Malec E, Januszewska K, Kolz J, Pajak J. Factors influencing early outcome of Norwood procedure for hypoplastic left heart syndrome Eur J Cardiothorac Surg 2000;18:202-206.[Abstract/Free Full Text]
  20. Rychik J, Rome JJ, Collins MH, DeCampli WM, Spray TL. The hypoplastic left heart syndrome with intact atrial septumatrial morphology, pulmonary vascular histopathology and outcome. J Am Coll Cardiol 1999;34:554-560.[Abstract/Free Full Text]
  21. Forbess JM, Cook N, Roth SJ, Serraf A, Mayer Jr JE, Jonas RA. Ten-year institutional experience with palliative surgery for hypoplastic left heart syndrome. Risk factors related to stage I mortality Circulation 1995;92(9 Suppl):II262-II266.
  22. Bartram U, Grunenfelder J, Van Praagh R. Causes of death after the modified Norwood procedurea study of 122 postmortem cases. Ann Thorac Surg 1997;64:1795-1802.[Abstract/Free Full Text]
  23. Ghanayem NS, Cava JR, Jaquiss RD, Tweddell JS. Home monitoring of infants after stage one palliation for hypoplastic left heart syndrome Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2004;7:32-38.[Medline]
  24. Maher KO, Gidding SS, Baffa JM, Pizarro C, Norwood Jr WI. New developments in the treatment of hypoplastic left heart syndrome Minerva Pediatr 2004;56:41-49.[Medline]
  25. Pizarro C, Norwood WI. Right ventricle to pulmonary artery conduit has a favorable impact on postoperative physiology after stage I Norwoodpreliminary results. Eur J Cardiothorac Surg 2003;23:991-995.[Abstract/Free Full Text]
  26. Malec E, Januszewska K, Kolcz J, Mroczek T. Right ventricle-to-pulmonary artery shunt versus modified Blalock-Taussig shunt in the Norwood procedure for hypoplastic left heart syndrome-influence on early and late haemodynamic status Eur J Cardiothorac Surg 2003;23:728-734.[Abstract/Free Full Text]
  27. Norwood WI, Kirklin JK, Sanders SP. Hypoplastic left heart syndromeexperience with palliative surgery. Am J Cardiol 1980;45:87-91.[Medline]
  28. Ungerleider RM, Shen I, Burch G, Butler R, Silberbach M. Use of routine ventricular assist following the first stage Norwood procedure Cardiol Young 2004;14(Suppl 1):61-64.
  29. Hoffman GM, Tweddell JS, Ghanayem NS, et al. Alteration of the critical arteriovenous oxygen saturation relationship by sustained afterload reduction after the Norwood procedure J Thorac Cardiovasc Surg 2004;127:738-745.[Abstract/Free Full Text]
  30. De Oliveira NC, Ashburn DA, Khalid F, et al. Prevention of early sudden circulatory collapse after the Norwood operation Circulation 2004;110(11 Suppl 1):II133-II138.
  31. Bradley SM, Atz AM, Simsic JM. Redefining the impact of oxygen and hyperventilation after the Norwood procedure J Thorac Cardiovasc Surg 2004;127:473-480.[Abstract/Free Full Text]
  32. Tchervenkov CI, Chu VF, Shum-Tim D, Laliberte E, Reyes TU. Norwood operation without circulatory arresta new surgical technique. Ann Thorac Surg 2000;70:1730-1733.[Abstract/Free Full Text]
  33. Poirier NC, Drummond-Webb JJ, Hisamochi K, Imamura M, Harrison AM, Mee RB. Modified Norwood procedure with a high-flow cardiopulmonary bypass strategy results in low mortality without late arch obstruction J Thorac Cardiovasc Surg 2000;120:875-884.[Abstract/Free Full Text]
  34. Sano S, Ishino K, Kawada M, Honjo O. Right ventricle-pulmonary artery shunt in first-stage palliation of hypoplastic left heart syndrome Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2004;7:22-31.[Medline]
  35. Maher KO, Pizarro C, Gidding SS, et al. Hemodynamic profile after the Norwood procedure with right ventricle to pulmonary artery conduit Circulation 2003;108:782-784.[Abstract/Free Full Text]
  36. Donnelly JP, Raffel DM, Shulkin BL, et al. Resting coronary flow and coronary flow reserve in human infants after repair or palliation of congenital heart defects as measured by positron emission tomography J Thorac Cardiovasc Surg 1998;115:103-110.[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 Ann. Thorac. Surg.Home page
J. Caspi, T. W. Pettitt, T. Mulder, and A. Stopa
Development of the pulmonary arteries after the norwood procedure: comparison between blalock-taussig shunt and right ventricular-pulmonary artery conduit.
Ann. Thorac. Surg., October 1, 2008; 86(4): 1299 - 1304.
[Abstract] [Full Text] [PDF]

Home page
 CirculationHome page
J. Atallah, I. A. Dinu, A. R. Joffe, C. M.T. Robertson, R. S. Sauve, J. D. Dyck, D. B. Ross, I. M. Rebeyka, and the Western Canadian Complex Pediatric Therapies F
Two-Year Survival and Mental and Psychomotor Outcomes After the Norwood Procedure: An Analysis of the Modified Blalock-Taussig Shunt and Right Ventricle-to-Pulmonary Artery Shunt Surgical Eras
Circulation, September 30, 2008; 118(14): 1410 - 1418.
[Abstract] [Full Text] [PDF]

Home page
 J Am Coll CardiolHome page
M. A. Scheurer, J. W. Salvin, V. L. Vida, F. Fynn-Thompson, E. A. Bacha, F. A. Pigula, J. E. Mayer Jr, P. J. del Nido, D. L. Wessel, P. C. Laussen, et al.
Survival and clinical course at fontan after stage one palliation with either a modified blalock-taussig shunt or a right ventricle to pulmonary artery conduit.
J. Am. Coll. Cardiol., July 1, 2008; 52(1): 52 - 59.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
S. M. Bradley, C. C. Erdem, T.-Y. Hsia, A. M. Atz, V. Bandisode, and J. M. Ringewald
Right Ventricle-to-Pulmonary Artery Shunt: Alternative Palliation in Infants With Inadequate Pulmonary Blood Flow Prior to Two-Ventricle Repair.
Ann. Thorac. Surg., July 1, 2008; 86(1): 183 - 188.
[Abstract] [Full Text] [PDF]

Home page
 Eur. J. Cardiothorac. Surg.Home page
C. Pizarro, C. D. Derby, J. M. Baffa, K. A. Murdison, and W. A. Radtke
Improving the outcome of high-risk neonates with hypoplastic left heart syndrome: hybrid procedure or conventional surgical palliation?
Eur. J. Cardiothorac. Surg., April 1, 2008; 33(4): 613 - 618.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
L. Lai, P. C. Laussen, C. L. Cua, D. L. Wessel, J. M. Costello, P. J. del Nido, J. E. Mayer, and R. R. Thiagarajan
Outcomes After Bidirectional Glenn Operation: Blalock-Taussig Shunt Versus Right Ventricle-to-Pulmonary Artery Conduit
Ann. Thorac. Surg., May 1, 2007; 83(5): 1768 - 1773.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
K. N. Fenton, K. Lessman, K. Glogowski, S. Fogg, and K. F. Duncan
Cerebral Oxygen Saturation Does Not Normalize Until After Stage 2 Single Ventricle Palliation
Ann. Thorac. Surg., April 1, 2007; 83(4): 1431 - 1436.
[Abstract] [Full Text] [PDF]

Home page
 AAP Grand RoundsHome page
K. Booth
Surgical Outcome for Hypoplastic Left Heart Syndrome
AAP Grand Rounds, September 1, 2006; 16(3): 29 - 30.
[Full Text] [PDF]

Home page
 CirculationHome page
O. Reinhartz, V. M. Reddy, E. Petrossian, M. MacDonald, J. J. Lamberti, S. J. Roth, G. E. Wright, S. B. Perry, S. Suleman, and F. L. Hanley
Homograft Valved Right Ventricle to Pulmonary Artery Conduit as a Modification of the Norwood Procedure
Circulation, July 4, 2006; 114(1_suppl): I-594 - I-599.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Peter C. Laussen
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Cua, C. L.
Right arrow Articles by Feltes, T. F.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Cua, C. L.
Right arrow Articles by Feltes, T. F.
Related Collections
Right arrow Congenital - cyanotic

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS