Steps of the Norwood Procedure

1. The surgeon will start with a median sternotomy.

2. Marking suture is placed on the right side of the ascending aorta to help guide the incision that will be made there later.

3. Bypass is started

4. A suture ligature is tied around the proximal ductus with care to avoid distortion of the takeoffs of the right and left pulmonary arteries. Before, these pulmonary arteries used to be controlled by using tourniquets but that led to narrowing in the branch of the of the pulmonary arteries and sudden and severe enlargement of the ventricle.

5. The child is cooled to a temperature of less than 18 degrees Celsius, and the main pulmonary artery is divided 2-3mm. Then the divided pulmonary artery is closed on the side further away from the pulmonary valve (distal main pulmonary artery).

6. On the underside of the aortic arch and down the ascending aorta a cut is made.

7. A V-shaped incision is made in the proximal divided main pulmonary artery (the part closer the pulmonary valve). Then an incisions is made in the distal pulmonary artery, which should be sutured, and a shano shunt is placed in the incision to connect it to this part of the pulmonary artery.

8. The other side of the shano shunt is then connected to the right ventricle through a short incision on the right ventricle that is directed leftward.

9. An internal pledget should be placed at the heel of the connection to reduce the risk of the suture cutting through the soft muscle.

10. A femoral vein graft that is of appropriate size is used to enlarge the ascending aorta. The homograft starts of as a tube that is then split open for the connection to the ascending aorta. The arch is then shaped to prevent the compression of the left pulmonary artery. Sutures are then placed at the place that the proximal main pulmonary artery is connected to the ascending aorta in order to minimize the risk of decreasing the coronary blood flow.