CLINICS 2012;67(5):521-524 TECHNICAL NOTE DOI:10.6061/clinics/2012(05)20 A new technique for the correction of hypoplastic left heart syndrome Roberto Rocha-e-Silva Hospital das Cl´ınicas, Instituto do Corac¸a˜ o, S a˜o Paulo, Brazil. Email: rochaesilva@incor.usp.br Tel.: 55 11 2661 5014 INTRODUCTION Hypoplastic left heart syndrome (HLHS) inevitably results in death within a few weeks of birth, and the surgical treatment for this condition involves three complex surgeries that are associated with a high mortality and cost (1). The mortality rates for the first-stage procedure range from 25-80% at medical centers worldwide. Moreover, many children (possibly as many as 50%, according to hospitals where accurate records are kept) with this disease are not referred for surgery and progress to death within days or weeks (2-4). The two conventional techniques that are used for the Norwood procedure (the first-stage surgical correction) involve the construction of a systemic pulmon- ary shunt. This procedure performed using the Blalock- Taussig technique leads to a diastolic systemic pulmonary flow that mimics systemic valve insufficiency. When performed using the Sano modification technique, the Norwood procedure involves building a tube between the systemic ventricle and the pulmonary artery; this technique avoids the diastolic systemic pulmonary flow but allows the blood in the lungs to reflux to the single ventricle, which increases the volume overload. This overload associated with ventriculotomy may lead to dysfunction of the ventricle and arrhythmia. Moreover, both techniques necessitate the use of an artificial tube and carry a risk for thrombosis or stenosis (5-9). Additionally, fabrication of the neo-aorta is a laborious technique that requires the extended use of extracorporeal circulation (ECC). Hybrid approaches involving the maintenance of the patent ductus arteriosus with the implantation of a stent (10,11) or the prolonged administration of prostaglandin E1 (12) associated with the banding of the pulmonary branches simplifies the surgical approach but have yielded unsatis- factory results (13,14). PROPOSED PROCEDURE FOR THE CORRECTION OF HLHS, STAGE 1 1. 2. Typical preparations for an intracardiac operation with ECC. Median sternotomy. Copyright 2012 CLINICS – This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non- commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. No potential conflict of interest was reported. 521 3. Dissection of the brachiocephalic trunk and implanta- tion of a 3.5-mm Gore-Tex graft for arterial ECC access. 4. Dissection and cannulation of the femoral artery as a second route of arterial access to maintain systemic perfusion after aortic clamping. 5. Cannulation of both venae cavae. 6. Placement of tourniquets in the left carotid artery, left subclavian artery and descending aorta after the insertion of the ductus arteriosus. 7. Initiation of ECC and ligation of the ductus arteriosus. 8. Placement of a clamp at the aortic arch to isolate the ascending aorta and the brachiocephalic trunk from the systemic circulation, which serves to maintain the cerebral, right superior limb and coronary perfusion. 9. Closure of the left carotid artery, left subclavian artery and descending aorta tourniquets with the continued maintenance of the descending aortic circulation via the femoral cannula. 10. Autologous tissue is formed into a flap using a semilunar section of the initial portion of the anterior pulmonary trunk 3 cm above the pulmonary valve (Figure 1). 11. A second semilunar incision is made into the anterosuperior side of the aortic arch near the left carotid and left subclavian artery to create a second flap of autologous tissue (Figure 1A). 12. Introduction of a 5-mm catheter through the opening of the pulmonary artery towards the pulmonary branches. Around this catheter is placed the pulmon- ary trunk cerclage using cardiac tape sutured with 5-0 prolene. This procedure results in a systemic pulmon- ary shunt with autologous tissue (Figure 1B). 13. The free edges of the semilunar flaps of the aorta and pulmonary trunk are rotated and sutured edge-to- edge, originating the autologous posterior neo-aortic wall (Figure 2A). A second line of stitches is placed to dorsally exclude the ductus arteriosus tissue. 14. A valved bovine pericardium patch is implanted from the anterior opening of the pulmonary trunk to the aortic arch and extends to the beginning of the descending aorta to give rise to the anterior wall of the neo-aorta (Figure 2B). The opening of the valve is placed near the lower edge of the aortic arch. This valve prevents diastolic systemic reflow to the pulmonary arteries and improves coronary perfusion pressure through the ascending aorta (retrograde