Mechanical Circulatory Support Following Norwood Palliation

Abstract

Historically, mechanical circulatory support for the newborn, particularly those with a singleventricle physiology, such as hypoplastic left heart syndrome, has been limited to extracorporeal membrane oxygenation. The results using extracorporeal membrane oxygenation have been less than optimal, and the application of the Berlin Heart, the only pediatric ventricular assist device the Food and Drug Administration has approved to date, has also been unsuccessful. We present a compilation of techniques that can be applied to these infants. The key principle revolves around the cannulation technique (and cannula used), which involves the placement of an "aortic" cannula flush with the surface of the common atrium (avoiding any extracorporeal surface exposure within the heart chambers). Further, the application of a centrifugal pump allows for a quite effective decompression of the heart in this setting. Lastly, the described approach allows the provision of support in a rather simple fashion without the use of cardiopulmonary bypass support and without the need for a ventriculotomy.

A milestone in congenital cardiac surgery: Four decades of the Norwood procedure

“…In a recent years, Berlin Heart EXCOR devices were available in infants with a single ventricle who had undergone the Norwood procedure as mechanical circulatory support. 21 In 2003, Ghanayem et al published his report of home monitoring program interstage for patients after undergoing the Norwood procedure (with MBTS). 22 Home surveillance of puls oximetry, weight, and feedings, together with care coordination and timely interventions significally reduced interstage mortality (from 7% to 0%).…”

“…For patients with failing physiology, extracorporeal membrane oxygenation provided rescue therapy as a bridge to heart transplantant. In a recent years, Berlin Heart EXCOR devices were available in infants with a single ventricle who had undergone the Norwood procedure as mechanical circulatory support 21 . In 2003, Ghanayem et al published his report of home monitoring program interstage for patients after undergoing the Norwood procedure (with MBTS) 22 .…”

An overview of mechanical circulatory support in single-ventricle patients

“…When supporting patients after stage 1 of palliation, the device must provide flow to support both the systemic and pulmonary circulation. We have recently come to prefer a cannulation technique which utilizes the common atrium for inflow and the neoaorta as outflow (22). In our experience, we have found cannula selection to be very important in limiting thrombus formation.…”

“…With a Sano shunt, flow through the pulmonary circulation is dependent on blood within the failing ventricle, which is diminished in a ventricle that is decompressed. We have typically taken down the Sano shunt and created a BT shunt at the time of VAD implant; or, on occasion, we have disconnected the proximal aspect of the Sano and reattached it to the outflow graft of the VAD ( Figure 1) (22).…”