The Norwood procedure is the first of three surgeries required to treat single-ventricle conditions such as hypoplastic left heart syndrome (HLHS). Because the left side of the heart can’t be fixed, the series of surgeries rebuilds other parts of the heart. The Norwood procedure is performed in the baby’s first or second week of life.to redirect the blood flow. Three goals for the Norwood procedure: 1, Build a new aorta. 2, Direct blood from the right ventricle through the new aorta and on to the rest of the body. 3, Direct the right ventricle to pump blood to the lungs until the next surgery.

1. Norwood
Procedure
Manu Jacob
Perfusionist

2. The Norwood procedure is the first of three surgeries required to treat single-ventricle
conditions such as hypoplastic left heart syndrome (HLHS). Because the left side of the
heart can’t be fixed, the series of surgeries rebuilds other parts of the heart.
The Norwood procedure is performed in the baby’s first or second week of life.to
redirect the blood flow.
Three goals for the Norwood procedure:
1, Build a new aorta.
2, Direct blood from the right ventricle through the new aorta and on to the rest of the
body.
3, Direct the right ventricle to pump blood to the lungs until the next surgery.

3. What are the symptoms of hypoplastic left heart syndrome?
• Hypoplastic left heart syndrome symptoms may include:
• Cyanosis, or a grayish (in dark-skinned people) or bluish (in light-skinned people)
discoloration of skin, lips and nails.
• Difficulty breathing.
• Difficulty feeding.
• Lack of energy (lethargy).
• Rapid heartbeat.
• Sweaty, clammy or cool skin.
• Weak pulse.
• Newborns with HLHS don’t always show symptoms immediately. Instead, symptoms may
develop within a few hours or days of birth.

4. How is hypoplastic left heart syndrome diagnosed?
• A healthcare provider can make a hypoplastic left heart syndrome diagnosis with
information from harmless imaging.
• Your provider may do this during your pregnancy or soon after your baby is born.
• During pregnancy, healthcare providers use painless and non-invasive imaging methods
such as:
• Ultrasound
• Fetal echocardiogram (ultrasound) to evaluate your baby’s heart before birth.
• After your baby is born, healthcare providers diagnose the condition by observing
symptoms and examining test results. They may hear a heart murmur while using a
stethoscope to listen to your baby’s heart. This means blood isn’t flow

5. What tests will be done to diagnose hypoplastic left heart syndrome?
• Tests for a hypoplastic left heart syndrome diagnosis may include:
• Chest X-ray: This shows the size and shape of your baby’s heart and lungs.
• Echocardiogram: This ultrasound shows internal heart structures.
• Electrocardiogram (EKG): This measures electrical changes during a
heartbeat.
• Pulse oximetry screening: This tells how much oxygen is in your baby’s
bloodstream.

6. Complications of the treatment
• Some children may not make it from one surgery to the next. Also, they may have problems
after each surgery, such as:
• Issues with their right ventricle not working right.
• An aortic valve leak.
• Liver disease.
• Abnormal heart rhythms.
• Blood clots.
• Infection.
• Trouble eating.
• Seizures.
• Kidney problems.
• Cardiac arrest.

7. Can hypoplastic left heart syndrome (HLHS) be treated before birth?
• Operating during pregnancy is not a treatment for hypoplastic left heart syndrome.
• A fetal surgeon may choose to operate only to correct some conditions that might be
associated with poor HLHS outcomes or in babies who are developing HLHS.

8. Stage 1: Norwood procedure
• This operation will occur within several days of
birth. Depending on the type of heart defect,
different surgical procedures may be used,
including the Norwood procedure. The purpose
of this operation is to ensure that blood-flow is
controlled enough to prevent damage to the
heart and lungs, and that enough blood is
reaching the lungs to keep the child alive until
the second operation.

9. Stage 2: Hemi-Fontan or Glenn operation
• Called the hemi-Fontan or Glenn operation, the
second procedure usually occurs within six
months of birth. During this surgery the
superior vena cava — a large vein that carries
deoxygenated blood from the upper body into
the heart — is disconnected from the heart and
attached to the pulmonary artery. After this
operation, deoxygenated blood from the upper
body goes to the lungs without passing through
the heart.

10. Stage 3: Fontan procedure
• This operation, called the Fontan procedure, occurs at
approximately 1 1/2 to 3 years of age. During this surgery
the inferior vena cava, a large vein that carries
deoxygenated blood from the lower body into the heart, is
disconnected from the heart and attached to the pulmonary
artery. After this operation, all of the deoxygenated blood
from the body goes to the lungs without passing through
the heart.

11. • CPB and Systemic Cooling
CPB is initiated once the circuit is completed and the tourniquet around the PDA is snared.
Phentolamine 0.1 to 0.3 mg is given, and a full flow of 150 mL/kg/minute is maintained regardless of
temperature. pH stat acid-base management is maintained during cooling, with the temperature
slowly decreased to 18 °C over at least 20 minutes. A decellularized right hemi-pulmonary artery
homograft is preferred for arch reconstruction and is tailored into the shape of a sail or shark fin. The
patch should not be made too large, which can compromise the LPA, or too long, which tends to create
an acute angulation at the distal arch. The patch is folded along the RPA and then cut at a 30-degree
angle.
The brachiocephalic arteries and proximal DTA are dissected, and fine tourniquets are placed for later
control of the vessels. The MPA is transected immediately above the pulmonary commissures. This
leaves excess tissue on the left side of the pulmonary bifurcation that when closed primarily in a
sagittal plane augments the inherent deficit of tissue near the RPA.

12. Arterial and venous cannulation
• Cardiopulmonary bypass is established through innominate artery and bicaval cannulation.
• The innominate artery is cannulated using a 3.5-mm polytetrafluoroethylene conduit sutured
with a 7/0 polypropylene running suture. This anastomosis should be performed as distally as
possible on the innominate/carotid artery in order to leave enough space for the surgical field.
• The sealing of the suture line is checked with a heparinized saline solution injection and then
completed using a conventional surgical glue. After systemic heparinization and the deairing and
cannulation of the PTFE shunt, the pulmonary branches are double-looped with silastic vessel
loops using the Blalock technique, but they are left open.
• The superior vena cava (SVC) is cannulated by introducing a 12 Fr Pacifico venous cannula
through the right appendage. The choice of introducing the cannula through the appendage
arises from the need to reduce the chance of post-decannulation SVC stenosis. After the start
of CPB, the pulmonary branches are closed, and the inferior vena cava is cannulated.
• The patient is then cooled to 28-30°C and the caval veins are snared.

13. Separation From CPB
• During rewarming, continuous ultrafiltration is performed to maintain a
hematocrit value of 45% to 50%. The patient is weaned from CPB on low-
dose epinephrine and calcium infusions as the shunt is opened. Once adequate
hemodynamics and gas exchange are confirmed, protamine is administered,
and a peritoneal dialysis catheter is placed in addition to a tunneled double-
lumen catheter in the right atrium via the cannulation site. With the arch
anastomosis glued, bleeding is minimal, and in many cases blood products are
not required. Milrinone is typically initiated once there is generous blood
pressure. The pericardium is approximated, if possible, to facilitate entry into
the chest at resternotomy. The sternal incision is closed in approximately 80%
of patients. Peritoneal dialysis is initiated within 4 to 6 hours of admission to
the intensive care unit.

14. Post-Operative Hemodynamics Following the Norwood Procedure
• The post-stage I simulation produced a PA pressure of 22 mmHg and high-frequency oscillations
within the flow field indicating highly disturbed hemodynamics. Despite PA mean pressure
dropping to 14 mmHg,
• The pre-stage II model also produced high-frequency flow components and PA wall shear stress
increases. These suboptimal conditions may be necessary to ensure adequate PA flow throughout
the pre-stage II period, as the shunt becomes relatively smaller compared to the patient’s somatic
growth. In the future, CFD can be used to optimize shunt design and minimize these suboptimal
condition.

15. Intraoperative Trouble Shooting
• Trouble shooting D-CPB includes
• Comprehensive assessment
• Direct assessment of the heart (contractility and coronaries);
• Cerebral and somatic regional oximetry;
• Systemic oxygen saturations end-tidal to arterial pCO2 gradient;
• Direct ventricle to femoral arterial pressure measurements (advancing the atrial line into the ventricle)
• Selective transesophageal echocardiography
• Selective neoaortic root angiography (coronaries).
When present, we correct remediable problems. For poor function, and return to CPB and allow further
time for cardiac recovery with the heart decompressed along with increased inotropic support. If all these
measures fail, and convert to ECLS. And acknowledge, however, the potential variability in adherence to
this protocol and the importance of critical judgment, not only for determining the next level of
investigation (such as root angiography), but also for determining the correct intervention.erative Trouble
Shooting