Improved Results of Aortic Arch Reconstruction in the Norwood Procedure Sunita J. Ferns, MD, MRCPCH (UK), Chawki El Zein, MD, Siva Prasad Maruboyina,

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Improved Results of Aortic Arch Reconstruction in the Norwood Procedure Sunita J. Ferns, MD, MRCPCH (UK), Chawki El Zein, MD, Siva Prasad Maruboyina, MBBS, Sujata Subramanian, MD, Andrew H. Van Bergen, MD, Michel N. Ilbawi, MD The Annals of Thoracic Surgery Volume 102, Issue 1, Pages 178-185 (July 2016) DOI: 10.1016/j.athoracsur.2016.01.079 Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Hypoplastic left heart depicting arch anatomy preoperatively. The Annals of Thoracic Surgery 2016 102, 178-185DOI: (10.1016/j.athoracsur.2016.01.079) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 An incision is made across the coarctation, and the periductal area is completely excised. The incision across the coarctation is extended into the thoracic descending aorta beyond the second intercostal arteries. (A) Ascending aorta, (B) junction of the arch with the descending aorta, and (C) distal tip of the incision. The Annals of Thoracic Surgery 2016 102, 178-185DOI: (10.1016/j.athoracsur.2016.01.079) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 The longitudinal incision extends from the left lateral aspect of the ascending aorta to curve posteriorly and inferiorly to the anterior and medial aspect of the descending aorta. The inset demonstrates the relationship between the ascending (A) and descending (B) aorta planes of incision. (C) is the distal tip of the incision. The Annals of Thoracic Surgery 2016 102, 178-185DOI: (10.1016/j.athoracsur.2016.01.079) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Upper and lower body perfusion through ballooned catheters in the innominate artery and descending thoracic aorta. (A) Ascending aorta, (B) junction of the arch with the descending aorta, and (C) distal tip of the incision. The Annals of Thoracic Surgery 2016 102, 178-185DOI: (10.1016/j.athoracsur.2016.01.079) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 A T-shaped bovine pericardial patch is fashioned with the wider end length equal to the diameter of the pulmonary artery. The suture line starts at the junction of the arch (B) with the descending aorta (B), rather than at the distal tip of the incision (C). The Annals of Thoracic Surgery 2016 102, 178-185DOI: (10.1016/j.athoracsur.2016.01.079) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 The proximal end of the patch is cut and fashioned to fit into the proximal aortopulmonary anastomosis at B (junction of the arch with the descending aorta). The Annals of Thoracic Surgery 2016 102, 178-185DOI: (10.1016/j.athoracsur.2016.01.079) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 7 Final patch shape after completion of arch reconstruction showing (B) a cobra head enlargement of the distal end of the incision. The Annals of Thoracic Surgery 2016 102, 178-185DOI: (10.1016/j.athoracsur.2016.01.079) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 8 Traditional approach with an ellipsoid patch and suture line (B) starts at the distal end of the aortic incision (B). The Annals of Thoracic Surgery 2016 102, 178-185DOI: (10.1016/j.athoracsur.2016.01.079) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 9 Kaplan-Meier survival curves for groups MT and TT. (COGPS = coarctation groups; CUM = cumulative.) The Annals of Thoracic Surgery 2016 102, 178-185DOI: (10.1016/j.athoracsur.2016.01.079) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions