Routine use of mechanical ventricular assist following the Norwood procedure

Conventional postoperative management after the Norwood procedure in patients with hypoplastic left heart syndrome suffers from three main shortfalls. First, the early postoperative care is often labor-intensive and ironically (despite sometimes heroic efforts), when babies die, health care providers often feel like failures, and in the worst scenarios, surgeons or other physicians create cultures of blame. Second, hospital survival is inconsistent in most centers, especially the ones with small surgical volume and limited experience. Third, survivors often show evidence of significant neurologic impairment. To address these postoperative problems, we have adopted the strategy of routinely placing all our patients with hypoplastic left heart syndrome on mechanical circulatory support immediately after their Norwood procedure. No attempt was made to balance the systemic and pulmonary circulation. Because an oxygenator was not used in the circuit, a much lower level of anticoagulation was used. Once the lactate level normalized, the amount of mechanical circulatory support was weaned. Since January of 2001, 23 patients have been managed using this strategy. The average time of mechanical circulatory support was approximately 3 days and has decreased to 2 days in more recent experience. The overall incidence of complications was 22%, and overall hospital survival was 87%. Neurodevelopmental testing before the Glenn procedure was normal for all patients tested. Routine postoperative use of mechanical ventricular assist device can support the increased cardiac output demands of infants following Norwood procedure and results in a stable postoperative convalescence. This strategy can simplify postoperative management, lead to excellent hospital survival, and possibly augment cerebral oxygen delivery resulting in improved neurologic outcomes for these patients.