The Journal of Thoracic and Cardiovascular Surgery
Volume 133, Issue 3 , Pages 648-655, March 2007

Cerebral perfusion and oxygenation after the Norwood procedure: Comparison of right ventricle–pulmonary artery conduit with modified Blalock–Taussig shunt

  • Barry D. Kussman, MBBCh

      Affiliations

    • Department of Anesthesiology, Perioperative and Pain Medicine, Children’s Hospital Boston, Mass.
    • Department of Anaesthesia, Harvard Medical School, Boston, Mass
    • Corresponding Author InformationAddress for reprints: Barry D. Kussman, MBBCh, Department of Anesthesiology, Perioperative and Pain Medicine, Children’s Hospital Boston, 300 Longwood Ave, Boston, MA 02115.
    • ,
  • Kimberlee Gauvreau, ScD

      Affiliations

    • Department of Cardiology, Children’s Hospital Boston, Mass
    • Department of Pediatrics, Harvard Medical School, Boston, Mass
    • ,
  • James A. DiNardo, MD

      Affiliations

    • Department of Anesthesiology, Perioperative and Pain Medicine, Children’s Hospital Boston, Mass.
    • Department of Anaesthesia, Harvard Medical School, Boston, Mass
    • ,
  • Jane W. Newburger, MD, MPH

      Affiliations

    • Department of Cardiology, Children’s Hospital Boston, Mass
    • Department of Pediatrics, Harvard Medical School, Boston, Mass
    • ,
  • Andrew S. Mackie, MD, SM

      Affiliations

    • Department of Cardiology, Children’s Hospital Boston, Mass
    • Department of Pediatrics, Harvard Medical School, Boston, Mass
    • Current address: Division of Cardiology, The Montreal Children’s Hospital, 2300 Tupper St, Montreal, QC, Canada H3H 1P3.
    • ,
  • Karen L. Booth, MD

      Affiliations

    • Department of Cardiology, Children’s Hospital Boston, Mass
    • Department of Pediatrics, Harvard Medical School, Boston, Mass
    • Current address: Division of Pediatric Cardiology, Lucile Packard Children’s Hospital, 750 Welch Rd, Suite 325, Palo Alto, CA 94304.
    • ,
  • Pedro J. del Nido, MD, PhD

      Affiliations

    • Department of Cardiac Surgery, Children’s Hospital Boston, Mass.
    • Department of Surgery, Harvard Medical School, Boston, Mass.
    • ,
  • Stephen J. Roth, MD, MPH

      Affiliations

    • Department of Cardiology, Children’s Hospital Boston, Mass
    • Department of Pediatrics, Harvard Medical School, Boston, Mass
    • Current address: Division of Pediatric Cardiology, Lucile Packard Children’s Hospital, 750 Welch Rd, Suite 325, Palo Alto, CA 94304.
    • ,
  • Peter C. Laussen, MBBS

      Affiliations

    • Department of Anesthesiology, Perioperative and Pain Medicine, Children’s Hospital Boston, Mass.
    • Department of Cardiology, Children’s Hospital Boston, Mass
    • Department of Anaesthesia, Harvard Medical School, Boston, Mass
    • Department of Pediatrics, Harvard Medical School, Boston, Mass

Received 7 July 2006; received in revised form 25 August 2006; accepted 12 September 2006.

Objective

The proposed physiologic advantage of the modified Norwood procedure using a right ventricle–pulmonary artery conduit to supply pulmonary blood flow, compared with a modified Blalock–Taussig shunt, is reduced runoff from the systemic-to-pulmonary circulation during diastole, resulting in a higher diastolic blood pressure and improved systemic perfusion. We hypothesized that the modified Norwood procedure is associated with improved cerebral perfusion and oxygenation.

Methods

Transcranial Doppler sonography and near-infrared spectroscopy were performed in neonates undergoing the Norwood procedure with either a modified Blalock–Taussig shunt (n = 14) or right ventricle–pulmonary artery conduit (n = 13).

Results

Diastolic blood pressure was significantly higher in the right ventricle–pulmonary artery group at 6 hours after bypass (46 ± 7 vs 40 ± 4 mm Hg; P = .03), on postoperative day 1 (45 ± 6 vs 37 ± 5 mm Hg; P = .002), and on postoperative day 2 (46 ± 7 vs 37 ± 4 mm Hg; P = .001). Cerebral diastolic blood flow velocity did not differ significantly between groups at any time point or over time, but cerebral systolic blood flow velocity was higher over time in the Blalock–Taussig group (P = .01). No significant differences in regional cerebral oxygen saturation were found between groups at baseline or after bypass. Blood flow velocities and cerebral oxygen saturation did not differ significantly according to use of regional low-flow perfusion.

Conclusions

The higher diastolic blood pressure after the modified Norwood procedure is not associated with higher cerebral blood flow velocities or regional cerebral oxygen saturation. This may imply an equal vulnerability to the cerebral injury associated with hemodynamic instability in the early postoperative period.

CTSNet classification: 19, 21

Abbreviations and Acronyms: CBF, cerebral blood flow, CBFV, cerebral blood flow velocity, CPB, cardiopulmonary bypass, DHCA, deep hypothermic circulatory arrest, HLHS, hypoplastic left heart syndrome, POD, postoperative day, RLFP, regional low-flow cerebral perfusion, RV-PA, right ventricle–pulmonary artery, VD, peak end-diastolic flow velocity, VM, mean flow velocity, VS, peak systolic flow velocity

 

 Supported by the Department of Anesthesiology, Perioperative and Pain Medicine Funds, the Glaser Pediatric Research Network, and grant RRO02172 from the National Institutes of Health.

PII: S0022-5223(06)01768-5

doi:10.1016/j.jtcvs.2006.09.034

The Journal of Thoracic and Cardiovascular Surgery
Volume 133, Issue 3 , Pages 648-655, March 2007

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