Stage I Yasui (Modified Norwood/Sano) for Interrupted Aortic Arch Type A and Hypoplastic LVOT With a VSD in a 2 kg Neonate

The authors present a stage I Yasui procedure in the form of a modified Norwood/Sano for a 2 kg, 6-day-old neonate with interrupted aortic arch type A, large posterior malalignment ventricular septal defect, and severely hypoplastic left ventricular outflow tract (Z-score = – 4.5). The goal was to achieve two-ventricle repair considering he had two good-sized ventricles. In order to achieve this, either a Ross-Konno or a modified Yasui procedure was needed. Due to the patient’s small size, the authors elected to proceed with a Yasui procedure in a staged fashion.

Their preference was to modify the Sano conduit prior to initiation of cardiopulmonary bypass (CPB) by suturing the end of a 5 mm ringed Gore-Tex graft to a 7 mm aortic/pulmonary homograft valve. They believe this minimizes, if not eliminates, any additional volume overload as a result of free pulmonary regurgitation compared to the typical non-valved Sano conduits.

CPB was initiated via dual arterial (3 mm Gore-Tex graft to the innominate artery and ductus arteriosus cannulation), and single right atrial cannulation. On the beating heart, the distal Sano anastomosis was first constructed to the pulmonary artery bifurcation. In this case, and due to the small weight of the baby, they banded the Sano conduit slightly to 4 mm with two strips of bovine pericardium and medium sized clips to limit the pulmonary flow later. After cross-clamping and cardioplegia, the modified Damus-Kaye-Stansel (DKS) aortopulmonary anastomosis was constructed. The second arterial cannula was then removed, and the ductus arteriosus was doubly ligated and divided. The proximal descending aorta to the undersurface of the arch anastomosis was created using a running 7/0 prolene suture along the back wall, and a cut-back incision was made in the proximal descending aorta to ensure widely patent anastomosis. A decellularized pulmonary homograft patch was then used in a Norwood type fashion to augment the aortic anastomosis, arch, ascending aorta, and the DKS anteriorly. The authors trim the patch as they go, thus creating an adequately sized neo-aorta. Perfusion was then re-established to the head and the entire body with removal of all vessel loops and hemoclips. A limited right atriotomy was then performed and the ostium primum was resected to create unrestricted atrial communication. The proximal Sano conduit was then implanted into the right ventricular cavity using the “dunk technique.” The heart was then de-aired and the aortic cross clamp was removed. Epicardial echocardiography confirmed the patency of the aortic arch and the unobstructed flow in the Sano conduit with good ventricular function. The patient was decannulated and a common atrial line was placed. The patient tolerated the procedure well and the chest was closed in a delayed fashion three days later. He was extubated on the 4th postoperative day with excellent hemodynamics. The rest of his hospital stay was uneventful, apart from needing laparoscopic gastrostomy feeding tube prior to discharge.

References

1. Reinhartz O, Reddy VM, Petrossian E, MacDonald M, Lamberti JJ, Roth SJ, et al. Homograft valved right ventricle to pulmonary artery conduit as a modification of the Norwood procedure. Circulation. 2006 Jul 4;114(1 Suppl):I594-1599.
2. Said SM, Dearani JA. Norwood valved Sano shunt: Early reward versus late penalty? J Thorac Cardiovasc Surg. 2018 Apr;155(4):7.
3. Mascio CE, Spray TL. Distal Dunk for Right Ventricle to Pulmonary Artery Shunt in Stage 1 Palliation. Ann Thorac Surg. 2015 Dec;100(6):2381-2382.

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