Usefulness of the bidirectional Glenn procedure as staged reconstruction for the functional single ventricle

doi:10.1016/0002-9149(93)90914-X

The American Journal of Cardiology

Volume 71, Issue 11, 15 April 1993, Pages 959-962

https://doi.org/10.1016/0002-9149(93)90914-X Get rights and content

Abstract

The bidirectional Glenn operation may be particularly useful as an intermediate procedure before Fontan correction in high-risk patients. From October 1989 through February 1992, 50 patients 1 to 60 months old (median 12) have undergone a bidirectional Glenn operation. Diagnoses included hypoplastic left heart syndrome in 21 patients, pulmonary atresia with intact ventricular septum in 10, tricuspid valve atresia in 9, other complex univentricular heart defects in 9, and Ebstein's anomaly in 1. Mean pulmonary vascular resistance was 2.2 ± 0.2 Wood U (range 0.5 to 7.3) and mean pulmonary artery area Nakata index was 318 ± mm²/m² (range 80 to 821). Additional procedures were performed in 17 patients, including pulmonary artery reconstruction in 15 (29%) and bilateral caval anastomoses in 5 (10%). There were 4 hospital deaths (8%). Two deaths resulted from myocardial infarction in patients with pulmonary atresia with intact ventricular septum and sinusoids and 1 from severe pulmonary vascular disease in a patient with hypoplastic left heart syndrome. There was 1 late death from pneumonia. Actuarial survival is 92 ± 4% at 1 month and beyond, with a mean follow-up of 13.4 ± 1 months. Risk factor analysis showed that pulmonary vascular resistance >3 Wood U and pulmonary artery distortion were associated with increased mortality. Twelve patients have undergone a Fontan procedure at a mean duration after bidirectional Glenn of 18 months with 1 death (8%). The bidirectional Glenn procedure provides excellent palliation in high-risk patients and appears useful as a staging procedure before Fontan correction.

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Cited by (152)

Surgical pulmonary arterioplasty at bidirectional cavopulmonary anastomosis leads to favorable pulmonary hemodynamics at final stage palliation
2024, JTCVS Open
Pulmonary arterioplasty (PA plasty) at bidirectional cavopulmonary anastomosis (BDCA) is associated with increased morbidity, but outcomes to final stage palliation are unknown. We sought to determine the influence of PA plasty on pulmonary artery growth and hemodyamics at Fontan.
We retrospectively reviewed clinical data and outcomes for BDCA patients from 2006 to 2018. PA plasty was categorized by extent (type 1-4), as previously described. Outcomes included pulmonary artery reintervention and mortality before final palliation.
Five hundred eighty-eight patients underwent BDCA. One hundred seventy-nine patients (30.0%) underwent concomitant PA plasty. Five hundred seventy (97%) patients (169 [94%] PA plasty) survived to BDCA discharge. One hundred forty out of 570 survivors (25%) required PA/Glenn reintervention before final stage palliation (59 out of 169 [35%]) PA plasty; 81 out of 401 (20%) non-PA plasty; P < .001). Twelve-, 24-, and 36-month freedom from reintervention after BDCA was 80% (95% CI, 74-86%), 75% (95% CI, 69-82%), and 64% (95% CI, 57-73%) for PA plasty, and 95% (95% CI, 93-97%), 91% (95% CI, 88-94%), and 81% (95% CI, 76-85%) for non-PA plasty (P < .001). Prefinal stage mortality was 37 (6.3%) (14 out of 169 PA plasty; 23 out of 401 non-PA plasty; P = .4). Five hundred four (144 PA plasty and 360 non-PA plasty) patients reached final stage palliation (471 Fontan, 26 1.5-ventricle, and 7 2-ventricular repair). Pre-Fontan PA pressure and pulmonary vascular resistance were 10 mm Hg (range, 9-12 mm Hg) and 1.6 mm Hg (range, 1.3-1.9 mm Hg) in PA plasty and 10 mm Hg (range, 8-12 mm Hg) and 1.5 mm Hg (range, 1.3-1.9 mm Hg) in non-PA plasty patients, respectively (P = .29, .6). Fontan hospital mortality, length of stay, and morbidity were similar.
PA plasty at BDCA does not confer additional mortality risk leading to final palliation. Despite increased pulmonary artery reintervention, there was reliable pulmonary artery growth and favorable pulmonary hemodynamics at final stage palliation.
Risk Factors for Failed Fontan Procedure After Stage 2 Palliation
2021, Annals of Thoracic Surgery
Our aim was to evaluate the results of stage 2 palliation by means of bidirectional cavopulmonary shunt (BCPS) and to identify risk factors for failed Fontan completion.
Between 1998 and 2018, BCPS was performed on 525 patients with functional single ventricle. Patient demographics, surgical data, and echocardiographic and cardiac catheterization measurements were analyzed, and outcomes after BCPS were evaluated.
The median age at BCPS was 4.7 months (interquartile range, 3 to 7.4). Hypoplastic left heart syndrome was the most frequent diagnosis. The median follow-up after BCPS was 3.4 years (interquartile range, 1.5 to 8.7); 407 patients underwent the Fontan procedure, 50 were waiting for Fontan completion, 47 died, 6 were considered not suitable for Fontan completion, and 15 were lost to follow-up. Of the 407 patients who underwent Fontan completion, there were 5 early deaths. Freedom from failed Fontan completion (mortality before, unsuitability for, and early mortality after the Fontan procedure) at 1, 2, and 3 years was 91.9%, 87.3%, and 86.1%, respectively. Risk factor analysis for failed Fontan completion revealed hypoplastic left heart syndrome (hazard ratio [HR] 4.1, P = .001), unbalanced atrioventricular septal defect (HR 10.1, P < .001), higher pulmonary artery pressure (HR 1.1, P = .040), and reduced ventricular function (HR 4.2, P = .001) as risks.
Stage 2 palliation can be performed with minimal risk and provides excellent subsequent Fontan completion. Hypoplastic left heart syndrome, unbalanced atrioventricular septal defect, high pulmonary artery pressure, and reduced ventricular function at the time of BCPS were identified as risk factors for failure to successfully complete the Fontan procedure.
Off-Pump Bidirectional Glenn Shunt in a Patient With Abdominal Aortic Thrombosis: Anesthesia and Perioperative Echocardiographic Perspective
2021, Journal of Cardiothoracic and Vascular Anesthesia
PATIENTS WITH A complex congenital cardiac condition are prone to develop polycythemia and vascular thrombosis due to long-standing cyanosis. Development of aortic thrombosis in the presence of deep cyanosis is one such vascular complication, which rarely has been reported in the literature.¹ Bidirectional Glenn (BDG) shunt is a palliative procedure that is routinely performed in patients with complex congenital heart diseases.² Surgery for BDG shunting is conventionally carried out with the institution of cardiopulmonary bypass (CPB). However, exposure to CPB in severely cyanotic patients may sometimes result in complications such as hemolysis, coagulation derangement, and organ injury.³ These complications can be avoided if the BDG can be performed without the establishment of CPB. Intraoperative echocardiography is a valuable monitoring tool during pediatric cardiac surgery. The authors present a case scenario in which the abdominal aortic thrombosis was detected incidentally in the intraoperative period. This patient was operated on for the BDG shunt without the institution of CPB. Echocardiography played a major perioperative role in the diagnosis and monitoring.
Outcome of patients with functional single ventricular heart after pacemaker implantation: What makes it poor, and what can we do?
2019, Heart Rhythm
Pacemaker implantation in patients with single ventricle is associated with poor outcomes.
The purpose of this study was to determine the reasons for the poor outcomes of pacemaker implantation.
We performed a retrospective chart review of patients with single ventricle who had undergone permanent pacemaker implantation. Patients were categorized into 3 groups based on the site of pacing and the proportion of ventricular pacing (VP) as follows: (1) atrial pacing group with atrial pacing only (n = 11); (2) low VP group with low daily VP proportion (<50%; n = 12); and (3) high VP group with high daily VP proportion (≥50%; n = 15). Pacing leads were placed at the epicardium in all patients.
No patients in the atrial pacing or low VP groups died, whereas the survival rate in the high VP group was 58.9% and 39.3% at 10 and 20 years, respectively, after pacemaker implantation. Among the post-Fontan patients, plasma brain natriuretic peptide (BNP) levels significantly increased with the proportion of VP: 11.7, 20.3, and 28.4 pg/mL in the atrial pacing, low VP, and high VP groups, respectively (P = 0.04). In the high VP group, the plasma BNP level was significantly lower in patients with an apical pacing lead than in those with a nonapical pacing lead (27.0 pg/mL vs 82.8 pg/mL, respectively; P = .03).
A higher proportion of VP was associated with poor outcome and higher plasma BNP levels, probably due to ventricular dyssynchrony. In epicardial ventricular pacing, apical pacing is better to avoid the increase in ventricular stress and plasma BNP level.
Need for Pulmonary Arterioplasty During Glenn Independently Predicts Inferior Surgical Outcome
2018, Annals of Thoracic Surgery
Bidirectional cavopulmonary anastomosis (BDCA) can be accomplished with low morbidity and mortality. The impact of concomitant pulmonary arterioplasty (PAplasty) is not known. We hypothesized that the need for and extent of PAplasty adversely affect BDCA outcomes.
Patients who underwent BDCA at our institution between 2006 and 2014 were included. Patient demographics, operative characteristics, mortality, and morbidity were analyzed. Serious physiologic adverse event following Glenn (GAE) was defined as need for extracorporeal support, BDCA takedown or percutaneous intervention during same admission, hospital length of stay 1 SD or more from mean, or need for supplemental oxygen at discharge. PAplasty was categorized according to extent. Data were analyzed using SAS 9.4 (SAS Institute, Cary, NC).
A total of 424 patients (231 boys, 54%) underwent BDCA for single ventricle physiology at a median of 7 (5.5 to 8.9) months of age and 6.5 (5.7 to 7.7) kg weight. A total of 112 (26%) patients required PAplasty: 23 were patch closures of the divided distal PA (type 1), 45 were central PA augmentations (type 2), 23 extended to the hilum on 1-branch PA (type 3), and 21 were bilateral hilum to hilum augmentation (type 4). Patients who required PAplasty tended to be significantly younger and more likely to have single right ventricles. There was no difference in PA pressure or resistance between patients who did and did not require PAplasty. Major Society of Thoracic Surgeons morbidity (13% vs 6%; p = 0.001), GAE (45% vs 34%; p = 0.04), and in-hospital mortality (5.4% vs 1.9%; p = 0.03) were higher in patients who required PAplasty compared with those who did not. Among the operative variables evaluated, need for PAplasty (hazard ratio [HR], 1.6; p = 0.03) independently predicted hospital mortality. Need for circulatory arrest (HR, 4; p = 0.005) and PAplasty (HR, 2.4; p = 0.0006) were independent predictors of Society of Thoracic Surgeons morbidity and need for PAplasty independently predicted GAE (HR, 1.8; p = 0.03).
The need for PAplasty at BDCA is an independent predictor of mortality and morbidity. It is important to consider this variable when developing outcome metrics for BDCA.
Primary Central Pulmonary Artery Plasty for Ductal-Associated Pulmonary Artery Coarctation
2020, Operative Techniques in Thoracic and Cardiovascular Surgery
Citation Excerpt :
On the contrary, exceedingly low antegrade PBF may result in a hypoplastic PA and aortopulmonary collateral arteries with high PVR. Recently, bidirectional cavopulmonary shunt (BCPS) has become a preferred staged procedure to Fontan completion for patients with functional SV including heterotaxy syndrome.2-5 However, some papers suggested that high PVR, PA distortion and severely unbalanced PA growth are risk factors for BCPS.6,7
Infants with functionally single ventricle who require a modified Blalock-Taussig shunt can have stenosis at the ductal insertion site on the pulmonary artery (PA), the so-called ductal-associated PA coarctation.
We hypothesized that central PA plasty with resection of the ductal tissue on the PA during the first palliation would prevent PA coarctation and obtain well-balanced PA for Fontan operation.
We performed this strategy on 40 consecutive patients (from 1998 to 2012, Age 38.4 ± 24.7 day [17 neonates], body weight 3.5 ± 0.8 kg, heterotaxy n = 27). The mean Nakata index (mm²/m²) before bidirectional cavopulmonary shunt was 230.7 ± 101.7 without pulmonary stenosis. The PA diameter ratio and lung perfusion ratio (nonshunt side and/or shunt side) were 0.93 ± 0.25 and 0.9 ± 0.2, respectively.
This strategy may improve clinical outcomes on functional single ventricle patients with increased risk of stenosis from pulmonary coarctation, with avoidance of an unbalanced pulmonary vascular bed.

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Usefulness of the bidirectional Glenn procedure as staged reconstruction for the functional single ventricle

Abstract

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Cardiol Clin

Ann Thorac Surg

Ann Thorac Surg