Ring-Reinforced Sano Right Ventricular to Pulmonary Artery Conduit at Norwood Stage I

The SVR trial showed that coronary perfusion pressure might be better supported by the Sano modification of Norwood stage 1 palliation of hypoplastic left heart syndrome. However, the Sano modification to stage I palliation carries its own downsides: the ventriculotomy required for this conduit may negatively impact late ventricular function and survival, and there is a high reintervention rate due to proximal obstruction. Several groups have worked on bringing technical modifications to the Sano RV-PA conduit in order to minimize these downsides. Tweddell et al. first described using a ring-reinforced ePTFE graft, which is placed or dunked into the right ventricle through a limited ventriculotomy (1). The authors have been using this technique routinely and illustrate their current surgical approach in this video. The authors have previously reported the results using this technique (2-4). In these experiences, there were fewer reinterventions on the proximal conduit and pulmonary arteries, and the PA pulse pressure and Nakata index were greater than in non-ringed controls. Further evaluation of late ventricular function is currently ongoing.

References

1. Tweddell JS, Mitchell ME, Woods RK, Spray TL, Quintessenza JA. Construction of the right ventricle-to-pulmonary artery conduit in the Norwood: the “Dunk” technique. Oper Tech Thorac Cardiovasc Surg 2012;17:81–98.
2. Baird CW, Myers PO, Borisuk M, Pigula FA, Emani SM. Ring-reinforced Sano conduit at Norwood stage I reduces proximal conduit obstruction. Ann Thorac Surg 2015;99:171–9.
3. Bentham JR, Baird CW, Porras DP, Rathod RH, Marshall AC. A reinforced right- ventricle-to-pulmonary-artery conduit for the stage-1 Norwood procedure improves pulmonary artery growth. J Thorac Cardiovasc Surg 2015;149:1502–8.
4. Myers, P. O., Emani, S. M., & Baird, C. W. (2016). Ring-reinforced Sano right ventricular to pulmonary artery conduit at Norwood stage I. Multimedia Manual of Cardio-Thoracic Surgery, 2016. http://doi.org/10.1093/mmcts/mmv038