Norwood-Sano Stage I Palliation for Hypoplastic Left Heart Syndrome: The Modified Birmingham Technique

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The patient was a 2.4 kg neonate diagnosed with hypoplastic left heart syndrome. The Birmingham technique of arch reconstruction in Stage I palliation aims to simplify the process of arch reconstruction during the Norwood procedure. This technique involves patch augmentation of the aortic arch and ascending aorta, combined with a direct anastomosis between the main pulmonary artery and the augmented arch. In this video, the authors demonstrate this technique, which includes the use of a valved Sano conduit. 
 
Prior to the skin incision, a modified Sano conduit was prepared with a 5 mm Gore-Tex graft and a 7 mm aortic valve homograft. The chest was then entered through a standard median sternotomy. An end-to-side anastomosis was created between a 3.5 mm Gore-Tex graft and the innominate artery. An 8 French arterial cannula was placed in this graft and was connected to the arterial limb of the cardiopulmonary bypass circuit. A 14 French cannula was also placed in the right atrium through the right atrial appendage. The ductus arteriosus was doubly ligated and divided. The main pulmonary artery was transected, and a pulmonary homograft was used to augment the pulmonary arterial confluence. The proximal insertion site for the Sano conduit was then created, and the “dunk” technique was used to place the graft. 
 
Cardioplegic arrest was then achieved, and the proximal descending thoracic aorta was clamped. Temporary clips were applied to the left common carotid and left subclavian arteries. Selective antegrade cerebral perfusion was then initiated. A cut back incision was made in the descending thoracic aorta, and the aortic arch was incised at its undersurface all the way down to the aortic root. A pulmonary homograft patch was then used to augment the aortic arch and the ascending aorta down to the aortic root.  

A limited right atriotomy and an atrial septectomy were performed to ensure unrestrictive atrial communication. The artriotomy was then closed in two layers. 
The aortic arch homograft was incised, and the main pulmonary artery was connected in an end-to-side fashion to the homograft patch, thus completing the neoaortic reconstruction. The patient swiftly regained normal sinus rhythm and was rewarmed back to normothermia. 
 
The distal anastomosis of the Sano conduit was completed by connecting the aortic valve homograft to the augmented area of the pulmonary arterial confluence. Following this, the patient was ventilated and weaned off cardiopulmonary bypass without difficulty. The authors were satisfied with these results, and all cannulas were removed. The chest was then temporarily closed. 
 
The bypass and cross-clamp times were 172 and 75 minutes, respectively, with selective cerebral perfusion lasting 49 minutes. The patient underwent standard chest closure 48 hours later and had an uneventful hospital stay. He was discharged two weeks later and continued to do well awaiting his Stage II palliation. 

References

1. Sakurai T, Rogers V, Stickley J, Khan N, Jones TJ, Barron DJ, Brawn WJ. Single-center experience of arch reconstruction in the setting of Norwood operation. Ann Thorac Surg. 2012 Nov;94(5):1534-9. doi: 10.1016/j.athoracsur.2012.05.097. Epub 2012 Jul 26. PMID: 22841016.
2. Barron DJ, Brooks A, Stickley J, Woolley SM, Stümper O, Jones TJ, Brawn WJ. The Norwood procedure using a right ventricle-pulmonary artery conduit: comparison of the right-sided versus left-sided conduit position. J Thorac Cardiovasc Surg. 2009 Sep;138(3):528-37. doi: 10.1016/j.jtcvs.2009.05.004. Epub 2009 Jul 9. PMID: 19698830.

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