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Eur J Cardiothorac Surg 2002;22:82-89
© 2002 Elsevier Science NL
a Division of Cardiothoracic Surgery, The Cardiac Center at The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Suite 8527, Philadelphia, PA 19104, USA
b Division of Cardiology, The Cardiac Center at The Children's Hospital of Philadelphia, Philadelphia, PA, USA
c Division of Biostatistics and Epidemiology, The Cardiac Center at The Children's Hospital of Philadelphia, Philadelphia, PA, USA
d Division of Cardiac Anesthesiology, The Cardiac Center at The Children's Hospital of Philadelphia, Philadelphia, PA, USA
Received 18 September 2001; received in revised form 7 March 2002; accepted 22 March 2002.
* Corresponding author. Tel.: +1-215-590-2708; fax: +1-215-590-2715
e-mail: gaynor{at}email.chop.edu
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Abstract |
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 Top Abstract 1. Introduction2. Methods3. Results4. DiscussionAppendix A. Conference...References |
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Key Words: Hypoplastic left heart syndrome • Norwood procedure
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1. Introduction |
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TopAbstract1. Introduction2. Methods3. Results4. DiscussionAppendix A. Conference...References |
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2. Methods |
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TopAbstract1. Introduction2. Methods3. Results4. DiscussionAppendix A. Conference...References |
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2.1. Statistical methods
Data were analyzed and compared for four groups of children: the entire cohort of children undergoing the Norwood procedure; the cohort of children who were operative survivors (survival to hospital discharge and at least 30 days post-operatively); the subgroup of children with HLHS; and in this subgroup, those with and without AA. Patient and operative variables were assessed as potential predictors of operative (hospital discharge and at least 30 days after surgery) and 1-year mortality (Table 2). Data are presented as medians and ranges.
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=0.01 level. The experiment-wise error rate was held constant at the =0.05 level using Westfall and Young's method for correlated endpoints [12]. Data were analyzed using STATA 7.0 (Stata Corporation 2000, College Station, TX, USA). The area under the receiver operating characteristic (ROC) curve is a measure of the predictive accuracy of the logistic model at different points of sensitivity and specificity (or 1 – specificity). The curve is generated by calculating the proportion of deaths predicted by the model among those who died as compared with the proportion of deaths predicted by the model among those who survived for different threshold values. Threshold values used in these ROC curves are determined by the predicted probabilities of death for each case in the logistic model. Thus, the area under the curve represents the probability that a randomly chosen predicted probability value from the death group exceeds that of a randomly chosen predicted probability value from the survivor group. The more a logistic model can distinguish between these groups, the closer the area under the ROC curve will be to one [13].
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3. Results |
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TopAbstract1. Introduction2. Methods3. Results4. DiscussionAppendix A. Conference...References |
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3.2. Logistic regression models
In the multivariable analysis for the entire cohort, the only characteristics which were associated with an increased risk of operative death were lower birth weight, an associated cardiac anomaly, longer total support time, and ECMO or VAD support (Table 2). Birth weight and weight at surgery was similar for the cohort; however, inclusion of birth weight resulted in a better fit of the model. Anatomic diagnosis (HLHS versus non-HLHS) was not a predictor of mortality (P=0.6). The area under ROC curve yielded a predictive accuracy of 87%. In the multivariable analysis for the HLHS patients alone (n=102), the only characteristics which increased the risk of operative death were lower birth weight, longer total support time, and ECMO or VAD support (Table 4). The presence of AA was not a predictor of operative death (P=0.3). The area under the ROC curve yielded a predictive accuracy of 89%.
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There were 15 deaths during the first year of life among the 122 children (12%) who survived the Norwood procedure; 11 occurred prior to the superior cavopulmonary connection, one at the time of the superior cavopulmonary connection at another institution, and three following superior cavopulmonary connection. Among the 11 deaths prior to superior cavopulmonary connection; eight were sudden unexplained cardiac deaths, one was secondary to respiratory syncitial viral infection, one occurred during readmission for shunt revision, and one was secondary to a cerebrovascular accident following cardiac catheterization. Among the three deaths following superior cavopulmonary connection; two were sudden unexplained deaths and one occurred during readmission for take-down of the superior cavopulmonary connection.
3.4. Survival analysis
For the entire cohort, the Kaplan–Meier survival estimate at 1 year was 66% (95% CL 58–73%) (Fig. 1
). Survival at 1 year was not different for patients with HLHS (64%, 95% CL 54–73%) compared to non-HLHS (68%, 95% CL 54–79%), P=0.6 (Fig. 2
). In the multivariable analysis, the characteristics which predicted mortality in the first year of life for the entire cohort were lower birth weight, an associated cardiac anomaly, an extra-cardiac anomaly or genetic syndrome, longer total support time, and ECMO or VAD support (Table 5). Among the HLHS cohort, characteristics which predicted 1-year mortality were similar; lower birth weight, an extra-cardiac anomaly, longer total support time, and ECMO or VAD support (Table 5). In the univariable analysis, there was lower survival at 1 year for patients with AA (57%, 95% CL 44–68%), compared to those without AA (81%, 95% CL 62–91%), P=0.05. However, in the multivariable analysis, AA was not a predictor of mortality (P=0.3). Survival to 1 year of age was significantly greater for patients weighing >2.5 kg at the time of the Norwood procedure without an associated anomaly (cardiac and/or extra-cardiac) (82%, 95% CL 71–89%), compared to the survival of patients with weight 
2.5 kg and/or an associated anomaly (cardiac and/or extra-cardiac) (48%, 95% CL 35–59%), P=0.0003 (Fig. 3
).
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4. Discussion |
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TopAbstract1. Introduction2. Methods3. Results4. DiscussionAppendix A. Conference...References |
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The early and late outcomes for children presenting with functional single ventricle and systemic outflow tract obstruction, including HLHS, have improved significantly since the introduction of the Norwood procedure. Mahle et al. [2] reported outcomes of 840 patients who underwent the Norwood procedure for HLHS between 1984 and 1999. The overall 1-year survival was 51%, however, there was a significant improvement in the mortality associated with the Norwood procedure in recent years. Later year of surgery was associated with significantly improved survival. Operative survival for the period 1995–1998 was 71.4%. Anatomic subtype was not a risk factor for death. Clancy et al. [8] assessed pre-operative predictors of operative mortality in a large group of neonates with congenital heart disease. Patients with functional single ventricle and systemic outflow tract obstruction had an increased operative mortality (26%), compared to other defects. Predictors of mortality in this group included presence of a genetic syndrome, decreased Apgar score, and increased age at hospital admission.
Many factors are likely responsible for the improvement in operative survival following the Norwood procedure including improved surgical techniques, improved perioperative management, and improved anesthetic techniques. Despite the improving outcome, early survival for these children is still significantly lower than for other forms of heart disease, which require neonatal surgical intervention. Factors which have been identified in multiple studies as potential predictors of mortality include low weight; presence of associated extra-cardiac defects or chromosomal abnormalities; presence of additional cardiac defects such as obstructed pulmonary venous drainage, total anomalous pulmonary venous connection, anomalous origin of the right subclavian artery; as well as operative factors such as prolonged CPB time [3–10]. Unlike the current study, some studies have suggested that the cardiac diagnosis remains a risk factor with less favorable outcomes for patients with HLHS as compared to other cardiac defects. Daebritz et al. [5] compared the results of the Norwood operation for patients with HLHS and those with other malformations in 194 patients who underwent surgery between 1990 and 1998. One hundred thirty-one patients had HLHS and 63 patients had other defects. In this study, the operative mortality was significantly greater for patients with HLHS (37%) compared to those with other defects (19%). One-year survival was also significantly lower for patients with HLHS (51%) compared to patients with other defects (71%). There was no difference in survival between the anatomic subgroups in the HLHS patients.
Low weight at the time of surgery has been identified as a predictor of mortality [3,4]. In 1999, Weinstein reported outcome following the Norwood procedure for 67 patients weighing 2.5 kg at the time of surgery between 1990 and 1997 with an operative mortality of 51% [4]. No variable could be correlated with increased mortality, although there was a trend toward increased mortality with increased CPB time and decreased ventricular function. The hospital survival for low weight infants of 62% in the current study suggests that the prognosis may be improving.
Of concern is the persistent incidence of death during the first year of life among patients who survived the initial hospitalization. In the current study, 12% of the survivors of the initial procedure died prior to 1 year of age, most before superior cavopulmonary connection. These deaths are usually sudden and often unexplained. Mahle et al. [11] evaluated the incidence of unexpected death among 536 patients with HLHS who survived the Norwood procedure. Unexpected death occurred in 4.1% of this large group of patients (22/536) at a median age of 79 days. A multivariable analysis demonstrated that perioperative arrhythmias and earlier era of surgical procedure were associated with an increased risk for unexpected death. No anatomic subtypes were found to be risk factors for death. In the current study, most of the late deaths occurred prior to the superior cavopulmonary connection; while mortality for this procedure is itself very low, 1/92 (1.1%). Multiple factors may be responsible for the unexplained deaths, including coronary insufficiency, arrhythmia, ventricular dysfunction, residual arch obstruction, pulmonary artery distortion, restrictive atrial septal defect, and inadequate pulmonary blood flow. However, in the current study, the only predictor of mortality in the first year of life for those who survived the Norwood procedure was the presence of associated anomalies (either cardiac or extra-cardiac). There was no difference in 1-year survival between patients with HLHS and other cardiac defects, however, there was a trend toward poorer survival for patients with AA as is reported in other studies. In the current study, AA was not a predictor of mortality in the multivariable analysis suggesting it is linked to other risk factors such as lower birth weight or associated anomalies. Patients with AA may be at risk for sudden death, secondary to the lack of antegrade aortic flow and abnormal coronary artery flow patterns. Some studies have suggested that patients with smaller ascending aortas have a worse outcome [6,7]. As operative survival continues to improve, it is important to identify patients at increased risk for death after hospital discharge and determine if modification of the treatment protocol can improve survival.
Associated cardiac defects have also been identified as risk factors for both operative and 1-year mortality in other studies as well [3–10]. Unfortunately, not every study reports the same defects. In the current study, associated cardiac defects included interrupted aortic arch, anomalies of pulmonary venous connection, obstruction to pulmonary venous drainage, anomalous origin of a subclavian artery, and atrioventricular valvar regurgitation. All of these have been implicated in other studies as predictors of mortality. The finding that additional cardiac defects are risk factors for both operative and 1-year mortality suggests that cardiac transplantation could be a better treatment strategy for some of these patients. However, many of these patients, particularly those with obstruction to pulmonary venous drainage, are difficult to stabilize medically while awaiting transplantation. Because of the increasing scarcity of appropriate donor organs as well as the mortality and morbidity while waiting for an organ, it is not clear that a strategy of primary transplantation would result in an improved outcome. Interestingly, associated extra-cardiac anomalies and genetic syndromes were predictors of 1 year of survival but were not associated with increased operative mortality. Thus, even though these patients may survive the initial procedure, the mid-term outcome is less favorable. Changing surgical treatment protocols are unlikely to improve outcome for this subgroup of patients, as they do not alter the underlying syndrome.
There are several limitations to this study. The retrospective nature precludes identification of risk factors not entered into the model. The presence of an associated cardiac defect was a predictor of both operative and 1-year mortality, however, the number of patients with each defect is small and it is not possible to evaluate the impact of each defect individually. In addition, there is a trend toward worse outcomes for patients with AA, however, data on the actual size of ascending aorta is not available.
In conclusion, the Norwood procedure is currently being applied to a heterogeneous group of patients with variable results in certain subgroups. The early survival for patients undergoing the Norwood procedure continues to improve, especially for patients of normal birth weight without associated anomalies. There is no difference in operative or 1-year survival for patients with HLHS, compared to those with other forms of functional single ventricle and systemic outflow tract obstruction. Much of the mortality risk, both operative and during the first year, is due to patient-related, rather than procedure-related variables, over which the medical and surgical teams have little control. The outcome for low birth weight infants has improved, but low weight remains a risk factor for mortality. In low-risk patients (i.e. those weighing >2.5 kg without additional cardiac or non-cardiac anomalies), the early risk of surgery is 8%, which is similar to other forms of critical heart disease requiring newborn surgical management. As operative survival following the Norwood procedure continues to improve, it is difficult to justify either non-intervention or primary transplantation. Inter-stage mortality remains a concern. The most important predictors of a poor outcome in the first year of life for patients who survive the initial hospitalization are the presence of additional cardiac or extra-cardiac defects. Additional studies are necessary to determine if changes in management strategy or patient selection may reduce this risk.
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Acknowledgments |
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Footnotes |
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Appendix A. Conference discussion |
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TopAbstract1. Introduction2. Methods3. Results4. DiscussionAppendix A. Conference...References |
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I know that in your institution you have a very standard way of filleting open the ascending aorta down to the transected main pulmonary artery stump and enlarge that to the homograft patch. But there are other ways of handling the ascending aorta, and one is to simply leave it all the way down from the aortic arch unopened, another way, as performed by Roger Mee, is to, in many cases, divide it and transect it and implant it into the reconstruction.
A couple of questions. One, have you done a stratification of the patients with respect to the size of the ascending aorta, particularly in the cases that there is AA with a small ascending aorta, 4 mm, 3 mm, less than 2, and what is the outcome in these patients with respect to ascending aortic size?
Would you care to comment on the importance of these three various techniques of reconstruction with respect to the coronary circulation, your technique, the modified Norwood, the one where the ascending aorta is left as a long coronary conduit from the aortic arch, as well as the technique of transection and implantation into the reconstruction?
Dr Spray: Unfortunately, I can't comment about the effect of aortic size because it was not consistently measured in this entire cohort. I do, however, think that the size of the ascending aorta is an issue. Obviously, when the ascending aorta is 1 mm in diameter, the technical issues of reconstructing the aortic arch are more complicated and the risk of coronary ischemia may be greater.
The reason the original Norwood operation involved opening the tiny ascending aorta down to the origins of the coronary arteries was to augment the entire ascending aorta and arch and to maintain the maximum inflow into the coronary arteries proximal to the takeoff of the shunt from the innominate artery. I think that it is in general a bad idea to leave the tiny ascending aorta with any significant length; the inflow into the common coronary artery. Because echo studies after the Norwood operation have shown that flow in the coronaries is primarily systolic rather than diastolic after the first stage operation, I am worried about shunt runoff causing coronary ischemia.
Reimplantation of the diminutive ascending aorta into the proximal pulmonary artery is another technique, which provides a more direct inflow into the coronaries proximal to the takeoff of the shunt. In essence, this technique is similar to the standard Norwood operation that puts the coronary at the same risk of stenosis. One has to decide where exactly to implant the aorta and a circumferential suture line is necessary in a very diminutive ascending aorta. I think if one prefers this technique, there is no real disadvantage but I am not sure there is a real advantage either.
My own personal prejudice is that in very tiny patients, a central shunt may be a better option than a modified Blalock–Taussig shunt using a 3 mm central shunt in a 1.2–1.5 kg baby.
Dr H. Jalahi (Brisbane, Australia): When we looked into our own results in Brisbane with a success rate of about 72%, there were a number of patients who had pre-operative pulmonary insufficiency of more than mild degree, mild to moderate. Have you encountered that problem, has it been an issue in your group, and how did you handle those patients, please?
Dr Spray: Pre-operative pulmonary insufficiency has not been common above a mild degree; when a patient has excessive pulmonary blood flow pre-operatively, sometimes functional pulmonary insufficiency will occur but this has not really been a problem late after the Norwood operation. I can only remember two patients in our overall experience with staged reconstruction who have required pulmonary valve surgery after staged reconstruction. Therefore, pulmonary insufficiency of the neoaorta seems to be quite rare. Tricuspid regurgitation is relatively common but rarely requires surgical intervention. When tricuspid regurgitation does require intervention, it is usually present at birth and reflects anatomic abnormalities of the tricuspid valve or the papillary muscles. It is possible that patients with severe tricuspid regurgitation at presentation are better served by cardiac transplantation.
Dr S. Sano (Okayama, Japan): I presented my new technique in Toronto and then have some comment about death after Norwood. And I think most of the presentation you do and Edward Bove do are very much similar. You have a huge experience of Norwood, and I think the mortality is higher in a low birth weight baby, small baby, and also a small ascending aorta, like aortic atresia. These are due to the coronary perfusion, malperfusion. So I think my technique of RV–PA shunt is useful to these low birth weight babies, especially small babies, and those with aortic atresia with very tiny ascending aortas. What do you think of the RV–PA shunt?
Dr Spray: I am intrigued by the use of an RV to PA shunt. While there are advantages to antegrade flow into the pulmonary arteries, it is also associated with pulmonary insufficiency and requires an incision in the right ventricle, which is the systemic ventricle. I believe many surgeons still have some concerns about making an incision in the systemic ventricle, however, when one reflects on your results, it is hard to say that RV function has been significantly altered. It would be valuable to see long term data of function of the right ventricular free wall.
I am intrigued that use of this technique may be beneficial in the very small patient. Obviously, when one is operating on a 1.2 kg baby, shunt selection is difficult and antegrade flow may be more easily accomplished with your technique
Dr Sano: I have done six patients out of 18 less than 2.5 kg. I lost one. And the post-operative management is very much the same of the patient with like a 3.1 kg baby. This is completely different.
Dr Spray: One interesting thing to me is the fact that the mortality after the Norwood operation has fundamentally changed over the last 5 years. The timing of mortality has also changed. Mortality usually doesn't occur in the first few days of after surgery now, but still occurs in the first 6 weeks after the Norwood operation and may be from other associated abnormalities. Sudden cardiovascular collapse is rarely the cause of mortality, while it used to be the most common sequence of events early after the first stage reconstruction. I do not know how much of the early mortality was ischemia in the past and how much ischemia contributes to the later mortality that we see today. I would love to be able to do PET scan on every one of these infants and look at coronary blood flow and perfusion, however, we have not been able to accomplish that yet in our own institution.
Dr Sano: In these 2 years I had no early deaths, no late deaths, no sudden deaths at all.
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TopAbstract1. Introduction2. Methods3. Results4. DiscussionAppendix A. Conference...References |
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S. Tabbutt, T. E. Dominguez, C. Ravishankar, B. S. Marino, P. J. Gruber, G. Wernovsky, J. W. Gaynor, S. C. Nicolson, and T. L. Spray Outcomes After the Stage I Reconstruction Comparing the Right Ventricular to Pulmonary Artery Conduit With the Modified Blalock Taussig Shunt Ann. Thorac. Surg., November 1, 2005; 80(5): 1582 - 1591. [Abstract] [Full Text] [PDF]
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 S. Schubert, G. Stoltenburg-Didinger, A. Wehsack, D. Troitzsch, W. Boettcher, M. Huebler, M. Redlin, M. Kanaan, M. Meissler, P. E. Lange, et al. Large-Dose Pretreatment with Methylprednisolone Fails to Attenuate Neuronal Injury After Deep Hypothermic Circulatory Arrest in a Neonatal Piglet Model Anesth. Analg., November 1, 2005; 101(5): 1311 - 1318. [Abstract] [Full Text] [PDF]
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B. Asfour, C. Fink, N. Sinzobahamvya, J. Wetter, A. E. Urban, and J. Photiadis Modified Children's II Operation on the Beating Heart Allows Growth Potential Ann. Thorac. Surg., October 1, 2005; 80(4): e14 - e16. [Abstract] [Full Text] [PDF]
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M. Ricci, P. Lombardi, A. Galindo, A. Vasquez, J. Zuccarelli, and E. Rosenkranz Distribution of cardiac output and oxygen delivery in an acute animal model of single-ventricle physiology J. Thorac. Cardiovasc. Surg., October 1, 2005; 130(4): 1062 - 1070. [Abstract] [Full Text] [PDF]
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M. Ricci, P. Lombardi, A. Galindo, E. Coscarella, A. Vasquez, and E. Rosenkranz Single-Ventricle Physiology Reduces Cerebral Oxygen Delivery in a Piglet Model Ann. Thorac. Surg., August 1, 2005; 80(2): 686 - 694. [Abstract] [Full Text] [PDF]
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C. L. Cua, R. R. Thiagarajan, R. Taeed, T. M. Hoffman, L. Lai, J. Hayes, P. C. Laussen, and T. F. Feltes Improved Interstage Mortality With the Modified Norwood Procedure: A Meta-Analysis Ann. Thorac. Surg., July 1, 2005; 80(1): 44 - 49. [Abstract] [Full Text] [PDF]
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J. Photiadis, M. Hubler, N. Sinzobahamvya, S. Ovroutski, B. Stiller, R. Hetzer, A. E. Urban, and B. Asfour Does size matter? Larger Blalock-Taussig shunt in the modified Norwood operation correlates with better hemodynamics Eur. J. Cardiothorac. Surg., July 1, 2005; 28(1): 56 - 60. [Abstract] [Full Text] [PDF]
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J. Photiadis, A. E. Urban, N. Sinzobahamvya, C. Fink, E. Schindler, M. Schneider, A. M. Brecher, and B. Asfour Restrictive left atrial outflow adversely affects outcome after the modified Norwood procedure Eur. J. Cardiothorac. Surg., June 1, 2005; 27(6): 962 - 967. [Abstract] [Full Text] [PDF]
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 D. Soetenga and K. A. Mussatto Management of Infants With Hypoplastic Left Heart Syndrome: Integrating Research Into Nursing Practice Crit. Care Nurse, December 1, 2004; 24(6): 46 - 66. [Full Text] [PDF]
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S. Sano, K. Ishino, H. Kado, Y. Shiokawa, K. Sakamoto, M. Yokota, and M. Kawada Outcome of Right Ventricle-to-Pulmonary Artery Shunt in First-Stage Palliation of Hypoplastic Left Heart Syndrome: A Multi-Institutional Study Ann. Thorac. Surg., December 1, 2004; 78(6): 1951 - 1958. [Abstract] [Full Text] [PDF]
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C. Pizarro, T. Mroczek, E. Malec, and W. I. Norwood Right Ventricle to Pulmonary Artery Conduit Reduces Interim Mortality After Stage 1 Norwood for Hypoplastic Left Heart Syndrome Ann. Thorac. Surg., December 1, 2004; 78(6): 1959 - 1964. [Abstract] [Full Text] [PDF]
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A. J. Lodge, J. Rychik, S. C. Nicolson, R. F. Ittenbach, T. L. Spray, and J. W. Gaynor Improving Outcomes in Functional Single Ventricle and Total Anomalous Pulmonary Venous Connection Ann. Thorac. Surg., November 1, 2004; 78(5): 1688 - 1695. [Abstract] [Full Text] [PDF]
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M. A. Mumtaz, R. B. B. Mee, A. Qureshi, C. R. Patel, and A. K. Younoszai HLHS With Severe Aortic Insufficiency in a Patient With 45,X/46,XY Mosaicism Ann. Thorac. Surg., October 1, 2004; 78(4): 1475 - 1476. [Abstract] [Full Text] [PDF]
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S. M. Bradley, J. M. Simsic, T. C. McQuinn, D. M. Habib, G. S. Shirali, and A. M. Atz Hemodynamic status after the Norwood procedure: A comparison of right ventricle-to-pulmonary artery connection versus modified blalock-taussig shunt Ann. Thorac. Surg., September 1, 2004; 78(3): 933 - 941. [Abstract] [Full Text] [PDF]
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A. Azakie and I. A. Russell Gender differences in pediatric cardiac surgery: The surgeon's perspective J. Thorac. Cardiovasc. Surg., July 1, 2004; 128(1): 4 - 6. [Full Text] [PDF]
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A. Azakie, D. Martinez, A. Sapru, J. Fineman, D. Teitel, and T. R. Karl Impact of right ventricle to pulmonary artery conduit on outcome of the modified norwood procedure Ann. Thorac. Surg., May 1, 2004; 77(5): 1727 - 1733. [Abstract] [Full Text] [PDF]
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R. M. Ungerleider, I. Shen, T. Yeh Jr, J. Schultz, R. Butler, M. Silberbach, C. Giacomuzzi, E. Heller, L. Studenberg, B. Mejak, et al. Routine mechanical ventricular assist following the Norwood procedure--improved neurologic outcome and excellent hospital survival Ann. Thorac. Surg., January 1, 2004; 77(1): 18 - 22. [Abstract] [Full Text] [PDF]
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W. T. Mahle, A. R. Cuadrado, and V. K. H. Tam Early experience with a modified norwood procedure using right ventricle to pulmonary artery conduit Ann. Thorac. Surg., October 1, 2003; 76(4): 1084 - 1088. [Abstract] [Full Text] [PDF]
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C. Pizarro, E. Malec, K. O. Maher, K. Januszewska, S. S. Gidding, K. A. Murdison, J. M. Baffa, and W. I. Norwood Right Ventricle to Pulmonary Artery Conduit Improves Outcome After Stage I Norwood for Hypoplastic Left Heart Syndrome Circulation, September 9, 2003; 108(90101): II-155 - 160. [Abstract] [Full Text] [PDF]
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C. Pizarro and W. I. Norwood Right ventricle to pulmonary artery conduit has a favorable impact on postoperative physiology after Stage I Norwood: preliminary results Eur. J. Cardiothorac. Surg., June 1, 2003; 23(6): 991 - 995. [Abstract] [Full Text] [PDF]
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M. B. Mitchell, D. N. Campbell, M. M. Boucek, H. M. Sondheimer, K. C. Chan, D. D. Ivy, B. Pietra, and T. Mackenzie Mechanical limitation of pulmonary blood flow facilitates heart transplantation in older infants with hypoplastic left heart syndrome Eur. J. Cardiothorac. Surg., May 1, 2003; 23(5): 735 - 742. [Abstract] [Full Text] [PDF]
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