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Baek JS, Park CS, Choi ES, Yun TJ, Kwon BS, Yu JJ, Kim YH. The impact of additional antegrade pulmonary blood flow at bidirectional Glenn shunt on long-term outcomes. J Thorac Cardiovasc Surg 2021; 162:1346-1355.e4. [PMID: 33612299 DOI: 10.1016/j.jtcvs.2021.01.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 01/04/2021] [Accepted: 01/06/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES We investigated the impact of additional antegrade pulmonary blood flow on the long-term outcomes after bidirectional Glenn shunt. METHODS From 2001 to 2015, 279 patients underwent bidirectional Glenn shunt as an interim palliation for a functionally single ventricle. After excluding patients with a previous Kawashima or Norwood operation, 202 patients with preexisting antegrade pulmonary blood flow before bidirectional Glenn shunt were included in this study. Antegrade pulmonary blood flow was eliminated in 110 patients (no antegrade pulmonary blood flow group) and maintained in 92 patients (antegrade pulmonary blood flow group). The impact of antegrade pulmonary blood flow at bidirectional Glenn shunt on long-term outcome was analyzed using inverse probability of treatment weighting. RESULTS Median age and body weight at bidirectional Glenn shunt were 8 months and 7.8 kg, respectively. Prolonged chest tube drainage or readmission for effusion after bidirectional Glenn shunt was more frequent in the antegrade pulmonary blood flow group (odds ratio, 3.067; 95% confidence interval, 1.036-9.073; P = .043). In the no antegrade pulmonary blood flow group, B-type natriuretic peptide level was decreased further until the Fontan operation (P = .012). In the no antegrade pulmonary blood flow group, oxygen saturation was lower just after bidirectional Glenn shunt, although it was increased further until Fontan operation (P < .001), despite still lower oxygen saturation before Fontan operation compared with antegrade pulmonary blood flow group (P < .001). The McGoon ratio was decreased in both groups without intergroup difference, although the McGoon ratio before Fontan operation was higher in the antegrade pulmonary blood flow group (2.3 ± 0.4 vs 2.1 ± 0.4, P = .008). Overall transplant-free survival was worse in the antegrade pulmonary blood flow group (hazard ratio, 2.37; confidence interval, 1.089-5.152; P = .030). CONCLUSIONS Maintaining antegrade pulmonary blood flow at bidirectional Glenn shunt was beneficial for higher oxygen saturation and larger pulmonary artery size before Fontan operation. However, it was unfavorable for overall transplant-free survival with a sustained higher risk of death or transplant until the elimination of antegrade pulmonary blood flow.
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Affiliation(s)
- Jae Suk Baek
- Division of Pediatric Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chun Soo Park
- Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Eun Seok Choi
- Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Jin Yun
- Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bo Sang Kwon
- Division of Pediatric Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Jin Yu
- Division of Pediatric Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Hwue Kim
- Division of Pediatric Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Choi RS, DiNardo JA, Brown ML. Superior Cavopulmonary Connection: Its Physiology, Limitations, and Anesthetic Implications. Semin Cardiothorac Vasc Anesth 2020; 24:337-348. [PMID: 32646291 DOI: 10.1177/1089253220939361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The superior cavopulmonary connection (SCPC) or "bidirectional Glenn" is an integral, intermediate stage in palliation of single ventricle patients to the Fontan procedure. The procedure, normally performed at 3 to 6 months of life, increases effective pulmonary blood flow and reduces the ventricular volume load in patients with single ventricle (parallel circulation) physiology. While the SCPC, with or without additional sources of pulmonary blood flow, cannot be considered a long-term palliation strategy, there are a subset of patients who require SCPC palliation for a longer interval than the typical patient. In this article, we will review the physiology of SCPC, the consequences of prolonged SCPC palliation, and modes of failure. We will also discuss strategies to augment pulmonary blood flow in the presence of an SCPC. The anesthetic considerations in SCPC patients will also be discussed, as these patients may present for noncardiac surgery from infancy to adulthood.
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Affiliation(s)
- Ray S Choi
- Children's Hospital Colorado, Denver, CO, USA.,Boston Children's Hospital, Boston, MA, USA
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Palliative Operations for Cyanotic Congenital Heart Disease with Severely Asymmetrical Pulmonary Arteries. Heart Lung Circ 2019; 29:780-784. [PMID: 31147189 DOI: 10.1016/j.hlc.2019.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 02/20/2019] [Accepted: 04/05/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Surgically managing patients with complex congenital heart disease and severely asymmetrical pulmonary arteries is challenging. Here, we report our experience using combined palliative procedures. METHOD The medical records of 28 patients with complex congenital heart disease and severely asymmetrical pulmonary arteries who underwent combined palliative procedures between January 2004 and April 2013 were retrospectively reviewed until January 2018. The patients were divided into three groups according to shunt procedure timing: in group A (n = 15), cavopulmonary and systemic-pulmonary shunting were performed simultaneously; in group B (n = 11), systemic-pulmonary shunting was performed first; and in group C (n = 2), cavopulmonary shunt was performed first. Patients were followed for a mean ± standard deviation of 4.18 ± 2.22 years. RESULTS No operative deaths occurred. There were no postoperative complications in groups B or C, but there was one case of pulmonary effusion and one of chylothorax in group A. The superior vena cava pressures were higher in patients in groups A and B than in those in group C. The ventilatory support duration and intensive care unit stays were longer in group A than in groups B and C (p < 0.01). Hypoplastic pulmonary artery development significantly improved after the use of three systemic-pulmonary shunts (p < 0.05), while the peripheral oxygen saturation increased from 67%±17% preoperatively to 85%±8% postoperatively (p < 0.001). Haemoglobin concentration decreased from 190 ± 34 g/L preoperatively to 136 ± 26 g/L postoperatively (p < 0.001). Two patients underwent double ventricle correction. Two patients underwent Fontan procedure. One patient underwent one and a half ventricle correction. One patient underwent collateral occlusion. CONCLUSIONS Combined palliative procedures can achieve acceptable arterial oxygen saturation without extra volume loading and rescue the hypoplastic pulmonary artery.
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Ephrem G, Hebson C, John A, Moore E, Jokhadar M, Ford R, Veldtman G, Dori Y, Gurvitz M, Kogon B, Kovacs A, Roswick M, McConnell M, Book WM, Rodriguez F. Frontiers in Fontan failure: Innovation and improving outcomes: A conference summary. CONGENIT HEART DIS 2018; 14:128-137. [PMID: 30343507 DOI: 10.1111/chd.12685] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 09/14/2018] [Indexed: 12/24/2022]
Abstract
The initial "Frontiers in Fontan Failure" conference in 2015 in Atlanta, GA, provided an opportunity for experts in the field of pediatric cardiology and adult congenital heart disease to focus on the etiology, physiology, and potential interventions for patients with "Failing Fontan" physiology. Four types of "Fontan Failure" were described and then published by Dr Book et al. The acknowledgment that even Dr Fontan himself realized that the Fontan procedure "imposed a gradually declining functional capacity and premature late death after an initial period of often excellent palliation." The purpose of the second "Frontiers in Fontan Failure" was to further the discussion regarding new data and technologies as well as novel interventions. The 2017 "Frontiers in Fontan Failure: Innovation and Improving Outcomes" was sponsored by Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, and Emory University School of Medicine. Future directions in the management of Fontan failure include further investigations into the risk of sudden cardiac death and how to properly prevent it, achievable interventions in modifying the Fontan physiology to treat or prevent late complications, and improved and refined algorithms in Fontan surveillance. Finally, further research into the interventional treatment of lymphatic-related complications hold the promise of marked improvement in the quality of life of advanced Fontan failure patients and as such should be encouraged and contributed to.
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Affiliation(s)
- Georges Ephrem
- Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| | - Camden Hebson
- Division of Cardiology, Department of Pediatrics, Children's of Alabama, Birmingham, Alabama
| | - Anitha John
- Division of Pediatric Cardiology, Children's National Health System, Washington, District of Columbia
| | - Estella Moore
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Maan Jokhadar
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Ryan Ford
- Division of Gastroenterology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Gruschen Veldtman
- Department of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Yoav Dori
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michelle Gurvitz
- Boston Children's Hospital, Boston, Massachusetts.,Brigham and Women's Hospital, Boston, Massachusetts
| | - Brian Kogon
- Division of Pediatric Cardiothoracic Surgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Adrienne Kovacs
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | | | - Michael McConnell
- Sibley Heart Center Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Wendy M Book
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Fred Rodriguez
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Sibley Heart Center Cardiology, Emory University School of Medicine, Atlanta, Georgia
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Si B, Qiao B, Yang G, Zhu M, Zhao F, Wang T, Li N, Ji X, Ding G. Numerical Investigation of the Effect of Additional Pulmonary Blood Flow on Patient-Specific Bilateral Bidirectional Glenn Hemodynamics. Cardiovasc Eng Technol 2018; 9:193-201. [PMID: 29359262 DOI: 10.1007/s13239-018-0341-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 01/12/2018] [Indexed: 10/18/2022]
Abstract
The effect of additional pulmonary blood flow (APBF) on the hemodynamics of bilateral bidirectional Glenn (BBDG) connection was marginally discussed in previous studies. This study assessed this effect using patient-specific numerical simulation. A 15-year-old female patient who underwent BBDG was enrolled in this study. Patient-specific anatomy, flow waveforms, and pressure tracings were obtained using computed tomography, Doppler ultrasound technology, and catheterization, respectively. Computational fluid dynamic simulations were performed to assess flow field and derived hemodynamic metrics of the BBDG connection with various APBF. APBF showed noticeable effects on the hemodynamics of the BBDG connection. It suppressed flow mixing in the connection, which resulted in a more antegrade flow structure. Also, as the APBF rate increases, both power loss and reflux in superior venae cavae (SVCs) monotonically increases while the flow ratio of the right to the left pulmonary artery (RPA/LPA) monotonically decreases. However, a non-monotonic relationship was observed between the APBF rate and indexed power loss. A high APBF rate may result in a good flow ratio of RPA/LPA but with the side effect of bad power loss and remarkable reflux in SVCs, and vice versa. A moderate APBF rate could be favourable because it leads to an optimal indexed power loss and achieves the acceptable flow ratio of RPA/LPA without causing severe power loss and reflux in SVCs. These findings suggest that patient-specific numerical simulation should be used to assist clinicians in determining an appropriate APBF rate based on desired outcomes on a patient-specific basis.
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Affiliation(s)
- Biao Si
- Department of Mechanics and Engineering Science, Fudan University, No. 220, Handan Road, Shanghai, China.,Institute of Cardiovascular Disease, General Hospital of Jinan Military Region, Jinan, China.,Institute of Computational Science and Cardiovascular Disease, Nanjing Medical University, Nanjing, China
| | - Bin Qiao
- Institute of Cardiovascular Disease, General Hospital of Jinan Military Region, Jinan, China.,Institute of Computational Science and Cardiovascular Disease, Nanjing Medical University, Nanjing, China
| | - Guang Yang
- Wuxi Mingci Cardiovascular Hospital, Wuxi, China
| | - Meng Zhu
- Institute of Cardiovascular Disease, General Hospital of Jinan Military Region, Jinan, China
| | - Fengyu Zhao
- Institute of Cardiovascular Disease, General Hospital of Jinan Military Region, Jinan, China
| | - Tongjian Wang
- Institute of Cardiovascular Disease, General Hospital of Jinan Military Region, Jinan, China
| | - Na Li
- Institute of Cardiovascular Disease, General Hospital of Jinan Military Region, Jinan, China
| | - Xiaopeng Ji
- Shandong Medical Imaging Research Institute, Shandong University, Jinan, China
| | - Guanghong Ding
- Department of Mechanics and Engineering Science, Fudan University, No. 220, Handan Road, Shanghai, China.
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Talwar S, Kumar MV, Sreenivas V, Gupta VP, Choudhary SK, Airan B. Exercise performance after univentricular palliation. Ann Pediatr Cardiol 2018; 11:40-47. [PMID: 29440829 PMCID: PMC5803976 DOI: 10.4103/apc.apc_43_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: The optimal timing, need for primary/staged procedure in patients undergoing univentricular palliation, is debatable. Aims: We performed this study to assess the exercise performance of patients undergoing various forms of univentricular palliation. Setting and Design: This was a retrospective, prospective comparative study conducted at a multispecialty tertiary referral center. Patients and Methods: Between January 2012 and June 2015, 117 patients undergoing either bidirectional Glenn (BDG) (n = 43) or Fontan (total cavopulmonary connection [TCPC]) (n = 74) underwent exercise testing. Statistical Analysis: Comparisons between subgroups for continuous data were made with Student's t-test if normally distributed and Wilcoxon rank-sum test otherwise. Tests between subgroups for qualitative data were made with Pearson's Chi-square test. Results: Patients who underwent BDG with open antegrade pulmonary blood flow (APBF) had higher saturations (oxygen saturation [SpO2]) compared to those without it (87.5 ± 5.0% vs. 81.1 ± 4.8%; P = 0.0001). However, we found no differences in exercise parameters of patients undergoing BDG with or without APBF. Extracardiac TCPC (n = 42) patients demonstrated better exercise capacity (15.0 ± 7.7 vs. 11.2 ± 6.2 min; P = 0.02) and increased SpO2 on exercise (87.0 ± 8.0% vs. 83.4 ± 7.6%; P ≤ 0.05) compared to lateral tunnel TCPC (n = 32). Fenestrated TCPC (n = 30) patients had higher exercise capacity reflected by higher metabolic equivalents (METs) consumption (6.4 ± 2.3 vs. 5.2 ± 2.0 METs, P = 0.02), fewer pleural effusions (7.0 ± 3.2 vs. 9.2 ± 6.2 days, P ≤ 0.05), and lower hospital stay (9.5 ± 4.0 vs. 12.7 ± 7.7 days, P = 0.04) compared to nonfenestrated TCPC (n = 44) patients. Conclusions: We observed no differences in exercise parameters of patients undergoing BDG with or without APBF. Extracardiac TCPC patients had better exercise capacity but longer postoperative hospital stay and pleural effusions than patients with lateral tunnel Fontan. Fenestrated TCPC patients seemed to fare better than nonfenestrated ones. Patients undergoing TCPC had better exercise capacity than patients undergoing BDG alone.
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Affiliation(s)
- Sachin Talwar
- Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Manikala Vinod Kumar
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | | | - Vishwa Prakash Gupta
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | | | - Balram Airan
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
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Metras A, Fouilloux V, Al-Yamani M, Roques X, Macé L, Thambo JB, Metras D, Kreitmann B, Roubertie F. Early to mid-term results after total cavopulmonary connection performed in the second decade of life. Interact Cardiovasc Thorac Surg 2017; 24:762-767. [PMID: 28453799 DOI: 10.1093/icvts/ivw427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 11/23/2016] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Total cavopulmonary connection (TCPC) performed in the second decade of life has rarely been studied. Thus, we investigated (bicentric study) early and late morbidity and mortality following completion of TCPC in these patients. METHODS From January 1999 to June 2014, 63 patients (14.5 ± 2.9 years) underwent TCPC (extracardiac conduit). Palliation before completion was an isolated bidirectional cavopulmonary shunt (BCPS) in 3 patients or BCPS associated with additional pulmonary blood flow (APBF) that was either antegrade (Group 1) in 38 (63%) or retrograde (Group 2) in 22 (37%). Preoperative and perioperative data were reviewed retrospectively. RESULTS Mean pulmonary arterial and ventricular end-diastolic pressures were 12.2 and 9.2 mmHg, respectively. Mean Nakata index was 279 ± 123 and 228 ± 87 mm 2 /m 2 in Groups 1 and 2, respectively ( P = 0.01). Aortic cross-clamping was performed in 22 from Group 1 and 8 from Group 2 ( P = 0.04). Mean follow-up was 4.57 years [0.8-15]. Nine patients had prolonged stays in the intensive care unit (>6 days). There were 1 early and 2 late deaths (non-cardiac related). Actuarial survival was 96% at 4 years. At last follow-up, single-ventricle function remained normal or improved in all patients (Group 1) compared to 82% in Group 2 ( P = 0.02). New York Heart Association (NYHA) class had improved in both groups: 47 patients were NYHA class II and 16 class III preoperatively vs 50 class I and 10 class II postoperatively ( P < 0.001). CONCLUSIONS Single-ventricle palliation with BCPS and APBF allowed completion of TCPC in the second decade of life, with encouraging mid-term results. However, BCPS with retrograde APBF was associated with single-ventricle dysfunction: thus, this technique needs to be used cautiously as long-lasting palliation.
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Affiliation(s)
- Alexandre Metras
- Department of Cardiovascular Surgery, Bordeaux Heart University Hospital, University of Bordeaux II, France
| | - Virginie Fouilloux
- Department of Cardiothoracic Surgery, Children's Hospital La Timone, Marseille, France
| | - Mohammed Al-Yamani
- Department of Cardiovascular Surgery, Bordeaux Heart University Hospital, University of Bordeaux II, France
| | - Xavier Roques
- Department of Cardiovascular Surgery, Bordeaux Heart University Hospital, University of Bordeaux II, France
| | - Loic Macé
- Department of Pediatric Cardiology, Bordeaux Heart University Hospital, University of Bordeaux II, France
| | - Jean-Benoît Thambo
- Department of Pediatric Cardiology, Bordeaux Heart University Hospital, University of Bordeaux II, France
| | - Dominique Metras
- Department of Cardiothoracic Surgery, Children's Hospital La Timone, Marseille, France
| | - Bernard Kreitmann
- Department of Cardiovascular Surgery, Bordeaux Heart University Hospital, University of Bordeaux II, France
| | - François Roubertie
- Department of Cardiovascular Surgery, Bordeaux Heart University Hospital, University of Bordeaux II, France
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Hebson C, Book W, Elder RW, Ford R, Jokhadar M, Kanter K, Kogon B, Kovacs AH, Levit RD, Lloyd M, Maher K, Reshamwala P, Rodriguez F, Romero R, Tejada T, Marie Valente A, Veldtman G, McConnell M. “Frontiers in Fontan failure: A summary of conference proceedings”. CONGENIT HEART DIS 2016; 12:6-16. [DOI: 10.1111/chd.12407] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 07/24/2016] [Indexed: 12/16/2022]
Affiliation(s)
- Camden Hebson
- Division of Cardiology; Department of Medicine, Emory University; Atlanta GA
- Division of Pediatric Cardiology; Department of Pediatrics, Emory University; Atlanta GA
| | - Wendy Book
- Division of Cardiology; Department of Medicine, Emory University; Atlanta GA
| | - Robert W. Elder
- Division of Cardiology; Department of Medicine, Yale University; New Haven CT
| | - Ryan Ford
- Division of Gastroenterology; Department of Medicine, Emory University; Atlanta GA
| | - Maan Jokhadar
- Division of Cardiology; Department of Medicine, Emory University; Atlanta GA
| | - Kirk Kanter
- Division of Cardiothoracic Surgery; Department of Surgery, Emory University; Atlanta GA
| | - Brian Kogon
- Division of Cardiothoracic Surgery; Department of Surgery, Emory University; Atlanta GA
| | - Adrienne H. Kovacs
- Division of Cardiology; Department of Medicine, Oregon Health and Science University; Portland OR
| | - Rebecca D. Levit
- Division of Cardiology; Department of Medicine, Emory University; Atlanta GA
| | - Michael Lloyd
- Division of Cardiology; Department of Medicine, Emory University; Atlanta GA
| | - Kevin Maher
- Division of Pediatric Cardiology; Department of Pediatrics, Emory University; Atlanta GA
| | - Preeti Reshamwala
- Division of Gastroenterology; Department of Medicine, Emory University; Atlanta GA
| | - Fred Rodriguez
- Division of Cardiology; Department of Medicine, Emory University; Atlanta GA
- Division of Pediatric Cardiology; Department of Pediatrics, Emory University; Atlanta GA
| | - Rene Romero
- Division of Pediatric Gastroenterology; Department of Pediatrics, Emory University; Atlanta GA
| | - Thor Tejada
- Division of Cardiology; Department of Medicine, Emory University; Atlanta GA
| | - Anne Marie Valente
- Division of Cardiology; Department of Medicine, Harvard University; Boston MA
| | - Gruschen Veldtman
- Division of Pediatric Cardiology; Department of Pediatrics, University of Cincinnati; Cincinnati OH
| | - Michael McConnell
- Division of Cardiology; Department of Medicine, Emory University; Atlanta GA
- Division of Pediatric Cardiology; Department of Pediatrics, Emory University; Atlanta GA
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Current outcomes of the bi-directional cavopulmonary anastomosis in single ventricle patients: analysis of risk factors for morbidity and mortality, and suitability for Fontan completion. Cardiol Young 2016; 26:288-97. [PMID: 25704070 DOI: 10.1017/s1047951115000153] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The bi-directional cavopulmonary anastomosis forms an essential staging procedure for univentricular hearts. This review aims to identify risk factors for morbidity, mortality, and suitability for Fontan completion. METHODS A total of 114 patients undergoing cavopulmonary anastomosis between 1992 and 2012 were reviewed to assess primary - mortality and survival to Fontan completion - and secondary outcome endpoints - re-intubation, new drain, and ICU stay. Median age and weight were 8 months and 6.9 kg, respectively. In 83% of patients, 1-3 interventions had preceded. Norwood-type procedures became more prevalent over time. RESULTS Extubation occurred after a median of 4 hours, median ICU stay was 2 days; 10 patients (8.8%) needed re-intubation and 18 received a new drain. Higher central venous pressure and transpulmonary gradient were risk factors for new drain insertion (p<0.01). Higher pre-operative pulmonary pressure correlated with increased inotropic support and prolonged intubation (p=0.01). Need for re-intubation was significantly affected by younger age at operation (p=0.01). Hospital and pre-Fontan mortality were 11.4 and 5.3%, respectively. Operative mortality was independently affected by younger age (p=0.013), lower weight (p=0.02), longer bypass time (p=0.04), and re-intubation (p=0.004). Interstage mortality was mainly influenced by moderate ventricular function (p=0.03); 82% of survivors underwent or are candidates for Fontan completion. CONCLUSION The cavopulmonary anastomosis remains associated with adverse outcomes. Age at operation decreases with rising prevalence of complex univentricular hearts. Considering the important impact of re-intubation on hospital mortality, peri-operative management should focus on optimising cardio-respiratory status. Once this selection step is taken, successful Fontan completion can be expected, provided that ventricular function is maintained.
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Davies RR, Pizarro C. Decision-Making for Surgery in the Management of Patients with Univentricular Heart. Front Pediatr 2015; 3:61. [PMID: 26284226 PMCID: PMC4515559 DOI: 10.3389/fped.2015.00061] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 06/21/2015] [Indexed: 12/24/2022] Open
Abstract
A series of technical refinements over the past 30 years, in combination with advances in perioperative management, have resulted in dramatic improvements in the survival of patients with univentricular heart. While the goal of single-ventricle palliation remains unchanged - normalization of the pressure and volume loads on the systemic ventricle, the strategies to achieve that goal have become more diverse. Optimal palliation relies on a thorough understanding of the changing physiology over the first years of life and the risks and consequences of each palliative strategy. This review describes how to optimize surgical decision-making in univentricular patients based on a current understanding of anatomy, physiology, and surgical palliation.
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Affiliation(s)
- Ryan Robert Davies
- Nemours Cardiac Center, A. I. duPont Hospital for Children , Wilmington, DE , USA ; Thomas Jefferson University , Philadelphia, PA , USA
| | - Christian Pizarro
- Nemours Cardiac Center, A. I. duPont Hospital for Children , Wilmington, DE , USA ; Thomas Jefferson University , Philadelphia, PA , USA
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The Modified Fontan Procedure With Use of Extracardiac Conduit in Adults: Analysis of 32 Consecutive Patients. Ann Thorac Surg 2014; 98:2181-6. [DOI: 10.1016/j.athoracsur.2014.07.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 07/03/2014] [Accepted: 07/23/2014] [Indexed: 11/21/2022]
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12
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Sen S, Bandyopadhyay B, Eriksson P, Chattopadhyay A. Functional capacity following univentricular repair--midterm outcome. CONGENIT HEART DIS 2012; 7:423-32. [PMID: 22471644 DOI: 10.1111/j.1747-0803.2012.00640.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Previous studies have seldom compared functional capacity in children following Fontan procedure alongside those with Glenn operation as destination therapy. We hypothesized that Fontan circulation enables better midterm submaximal exercise capacity as compared to Glenn physiology and evaluated this using the 6-minute walk test. DESIGN AND PATIENTS Fifty-seven children aged 5-18 years with Glenn (44) or Fontan (13) operations were evaluated with standard 6-minute walk protocols. RESULTS Baseline SpO(2) was significantly lower in Glenn patients younger than 10 years compared to Fontan counterparts and similar in the two groups in older children. Postexercise SpO(2) fell significantly in Glenn patients compared to the Fontan group. There was no statistically significant difference in baseline, postexercise, or postrecovery heart rates (HRs), or 6-minute walk distances in the two groups. Multiple regression analysis revealed lower resting HR, higher resting SpO(2) , and younger age at latest operation to be significant determinants of longer 6-minute walk distance. Multiple regression analysis also established that younger age at operation, higher resting SpO(2) , Fontan operation, lower resting HR, and lower postexercise HR were significant determinants of higher postexercise SpO(2) . Younger age at operation and exercise, lower resting HR and postexercise HR, higher resting SpO(2) and postexercise SpO(2) , and dominant ventricular morphology being left ventricular or indeterminate/mixed had significant association with better 6-minute work on multiple regression analysis. Lower resting HR had linear association with longer 6-minute walk distances in the Glenn patients. CONCLUSIONS Compared to Glenn physiology, Fontan operation did not have better submaximal exercise capacity assessed by walk distance or work on multiple regression analysis. Lower resting HR, higher resting SpO(2) , and younger age at operation were factors uniformly associated with better submaximal exercise capacity.
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Affiliation(s)
- Supratim Sen
- Department of Pediatric Cardiology, RN Tagore International Institute of Cardiac Sciences, Kolkata, India.
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Gérelli S, Boulitrop C, Van Steenberghe M, Maldonado D, Bojan M, Raisky O, Sidi D, Vouhé PR. Bidirectional cavopulmonary shunt with additional pulmonary blood flow: a failed or successful strategy? Eur J Cardiothorac Surg 2012; 42:513-9. [PMID: 22368190 DOI: 10.1093/ejcts/ezs053] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES In patients with single ventricle physiology, Fontan circulation is considered as the optimal surgical approach, although it entails a growing incidence of late complications. It has been speculated that the association of bidirectional cavopulmonary shunt (BCPS) and additional pulmonary blood flow (APBF) might provide long-lasting palliation. The present study was undertaken to assess the long-term outcome of this strategy. METHODS A group of 70 patients with single ventricle physiology, who underwent BCPS with APBF between 1990 and 2000, were reviewed retrospectively. Median age at operation was 2 years (range: 0.1-27 years). Unilateral BCPS was performed in 60 patients (86%), bilateral BCPS in 9 and the Kawashima procedure in 1. APBF was provided through antegrade pulmonary outflow tract in 43 patients (61%) and by aortopulmonary shunt in 27 (39%). Two patients died early and three were lost to follow-up. Mean follow-up of the 65 remaining patients was 13.5 ± 4 years. End-points were death, need for heart transplantation (HTx) or Fontan completion and functional outcome. RESULTS Five patients died (two after HTx, three from ventricular failure); overall actuarial survival was 89 ± 4% at 15 years. Six patients underwent HTx (one after Fontan completion) with two early deaths and no late mortality. Fifty-one patients underwent Fontan completion (11 with additional palliative procedures before completion); there was no early or late mortality following Fontan completion; one patient underwent HTx. Among the remaining six patients with BCPS and APBF, two were not suitable for Fontan completion and four remained suitable. Overall, clinical failure (mortality, HTx, unsuitability for Fontan completion) occurred in 13 patients (19%). Risk factors for clinical failure were older age at BCPS (P = 0.01) and postoperative complications after BCPS (P = 0.001). Considering late mortality, HTx and Fontan completion as strategic failures, the actuarial freedom from these events was 20 ± 5% at 10 years. CONCLUSIONS BCPS with APBF approach: (i) fails as a strategy for definitive palliation, (ii) provides a high survival rate, (iii) does not preclude a successful Fontan completion and (iv) may delay the long-term deleterious consequences of Fontan circulation. Palliation by BCPS with APBF should be achieved early in life.
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Affiliation(s)
- Sébastien Gérelli
- Department of Pediatric Cardiac Surgery, University Paris Descartes, Sorbonne Paris Cité and Sick Children Hospital, Paris, France
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Motoki N, Ohuchi H, Miyazaki A, Yamada O. Clinical Profiles of Adult Patients With Single Ventricular Physiology. Circ J 2009; 73:1711-6. [DOI: 10.1253/circj.cj-08-1155] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Noriko Motoki
- Department of Pediatrics, Shinshu University School of Medicine
| | - Hideo Ohuchi
- Department of Pediatrics, National Cardiovascular Center
| | - Aya Miyazaki
- Department of Pediatrics, National Cardiovascular Center
| | - Osamu Yamada
- Department of Pediatrics, National Cardiovascular Center
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Hussain A, Arfi AM, Hussamuddin M, Haneef AA, Jamjoom A, Al-Ata J, Mo G. Comparative outcome of bidirectional Glenn shunt in patients with pulmonary vascular resistance > or = 3.5 woods units versus < 3.5 woods units. Am J Cardiol 2008; 102:907-12. [PMID: 18805120 DOI: 10.1016/j.amjcard.2008.04.063] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2007] [Revised: 04/21/2008] [Accepted: 04/21/2008] [Indexed: 11/16/2022]
Abstract
Moderate to severe pulmonary hypertension is considered to be an absolute contraindication to the performance of bidirectional Glenn (BDG) shunting. However, BDG shunting has been performed in young children with pulmonary hypertension associated with unrestricted pulmonary blood flow. In this study, the medical records of patients who underwent BDG starting from October 2000 to March 2004 were reviewed. Patients were divided into 2 groups on the basis of indexed pulmonary vascular resistance (PVRI) measured in room air: a high-risk group (n = 12) with PVRI > or = 3.5 Woods units (WU)/m(2) and a low-risk group (n = 28) with PVRI <3.5 WU/m(2) in room air. The 2 groups were comparable with respect to age, weight, ventricular morphology, pulmonary arterial anatomy, and atrioventricular valve function. Mean pulmonary arterial pressure and PVRI were significantly higher in the high-risk group compared with the low-risk group (39.2 +/- 20.7 vs 15.1 +/- 6.25 mm Hg, p <0.002, and 6.0 +/- 2.5 vs 1.6 +/- 0.82 WU/m(2), p <0.0005, respectively). The ratio of pulmonary flow to systemic flow was 1.45 +/- 0.76 in the high-risk group and 1.24 +/- 1.2 in the low-risk group. In the high-risk group, mean PVRI decreased to 2.0 +/- 1.0 WU/m(2) on 100% oxygen (p <0.0005). A contraindication to Glenn shunting was PVRI >3.5 WU/m(2) on 100% oxygen. Hospital mortality was 17% (2 of 12) in the high-risk group and 4% (1 of 28) in the low-risk group. Of 10 survivors in the high-risk group, 1 had undergone a Kawashima procedure, 7 had undergone Fontan procedures (with 1 death), and 2 were awaiting the completion of Fontan procedures as of this writing. In conclusion, these preliminary data suggest that in young children with increased pulmonary flow, BDG shunting can be safely performed, despite the apparent elevation of pulmonary arterial pressure to inoperable levels, provided PVRI decreases to < or = 3.5 WU/m(2) on 100% oxygen.
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Affiliation(s)
- Arif Hussain
- King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia.
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16
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Calvaruso DF, Rubino A, Ocello S, Salviato N, Guardì D, Petruccelli DF, Cipriani A, Fattouch K, Agati S, Mignosa C, Zannini L, Marcelletti CF. Bidirectional Glenn and antegrade pulmonary blood flow: temporary or definitive palliation? Ann Thorac Surg 2008; 85:1389-95; discussion 1395-6. [PMID: 18355533 DOI: 10.1016/j.athoracsur.2008.01.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2006] [Revised: 01/01/2008] [Accepted: 01/02/2008] [Indexed: 11/17/2022]
Abstract
BACKGROUND We sought to investigate the role of the bidirectional Glenn with antegrade pulmonary blood flow in the surgical history of children with univentricular hearts. METHODS A series of 246 patients, from three joint institutions, having univentricular heart with restricted but not critical pulmonary blood flow received a bidirectional cavopulmonary shunt with additional forward pulmonary blood flow. All patients have been studied according to their progression, or not, to Fontan operation. Two hundred and eight (84.5%) patients underwent bidirectional cavopulmonary anastomosis as primary palliation. Twenty patients (8.1%) with previous pulmonary artery banding were also enrolled in the study. Patients who had received additional pulmonary blood flow through a previous systemic to pulmonary artery shunt for the critical pulmonary blood flow were excluded. RESULTS No in-hospital death occurred. Follow-up was complete at 100%. Mean follow-up was 4.2 +/- 2.8 years (range, 6 months to 7 years). During the observational period 73 (29.7%) patients, considered optimal candidates, underwent Fontan completion for increasing cyanosis and (or) hematocrit and (or) fatigue with exertion. Three patients expired after total cavopulmonary connection (3 of 73; 4.1% mortality rate). The remaining 173 (70.3%) patients are alive with initial palliation. All patients were still well palliated with an arterial oxygen saturation at rest about 90%. CONCLUSIONS According to our experience and results, bidirectional Glenn with antegrade pulmonary blood flow may be an excellent temporary palliation prior to a Fontan operation, which can be performed at the onset of symptoms. Bidirectional Glenn may also be the best possible palliation for a suboptimal candidate for Fontan.
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Affiliation(s)
- Davide F Calvaruso
- Department of Pediatric Cardiac Surgery Marta e Milagros, Azienda di Rilievo Nazionale e di Alta Specializzazione, Ospedale Civico, Palermo, Italy.
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Day RW, Etheridge SP, Veasy LG, Jenson CB, Hillman ND, Di Russo GB, Thorne JK, Doty DB, McGough EC, Hawkins JA. Single ventricle palliation: Greater risk of complications with the Fontan procedure than with the bidirectional Glenn procedure alone. Int J Cardiol 2006; 106:201-10. [PMID: 16321693 DOI: 10.1016/j.ijcard.2005.01.039] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2004] [Revised: 01/20/2005] [Accepted: 01/30/2005] [Indexed: 11/30/2022]
Abstract
BACKGROUND This study was performed to evaluate and compare the early, intermediate, and long-term outcomes of the bidirectional Glenn procedure and Fontan procedure in patients who live at moderately high altitude. METHODS The outcome of each method of palliation for patients with a functionally single ventricle was retrospectively evaluated from a review of medical records. RESULTS The bidirectional Glenn procedure was performed in 177 patients from October 1984 to June 2004. The Fontan procedure was performed in 149 patients from June 1978 to June 2004. Cardiovascular death or heart transplantation occurred in 8% of patients after the bidirectional Glenn procedure and 17% of patients after the Fontan procedure. Complications of systemic thromboembolic events, bleeding associated with anticoagulation therapy, protein losing enteropathy, and arrhythmias requiring implantation of a pacemaker, cardioversion, or radiofrequency ablation occurred in 7% of patients after the bidirectional Glenn procedure and 47% of patients after the Fontan procedure. Cardiovascular deaths and heart transplantation occurred less frequently when the Fontan procedure was performed in patients with a previous bidirectional Glenn procedure. However, the actuarial transplant-free survival and freedom from complications was not superior for a subgroup of patients who had a Fontan procedure after a bidirectional Glenn procedure in comparison to a subgroup of patients who had a bidirectional Glenn procedure alone. CONCLUSIONS The bidirectional Glenn procedure can be used for long-term palliation of patients with a functionally single ventricle. Additional palliation with a Fontan procedure may increase the risk of stroke, protein losing enteropathy and arrhythmias without improving survival.
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Affiliation(s)
- Ronald W Day
- Pediatric Cardiology, Primary Children's Medical Center, Salt Lake City, UT 84113, USA.
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