Influence of bidirectional superior cavopulmonary anastomosis on pulmonary arterial growth

doi:10.1016/S0002-9149(99)80307-5

The American Journal of Cardiology

Volume 76, Issue 14, 15 November 1995, Pages 1085-1087

https://doi.org/10.1016/S0002-9149(99)80307-5 Get rights and content

Abstract

Right-sided BSCA provides for satisfactory pulmonary arterial growth in infants and children with complex congenital heart defects, and it could enhance the growth of a small right pulmonary artery. The growth of the left pulmonary artery, particularly in younger patients, needs close attention to confirm the safe role of BSCA in long-term palliation.

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Cited by (28)

Impact of Antegrade Pulmonary Blood Flow as Patients Progress Through Single-Ventricle Palliations
2023, Annals of Thoracic Surgery
The impact of antegrade pulmonary blood flow (APBF) during single-ventricle (SV) palliation continues to be debated. We sought to assess its impact on the hemodynamic profile and the short- and long-term outcomes of patients progressing through stages of SV palliation.
A retrospective single-center study was conducted of SV patients who underwent surgery between January 2010 and December 2020. Patients with APBF were matched to those with no APBF by a propensity score based on body surface area, sex, and type of systemic ventricle. Analysis was performed using appropriate statistics with a significance level of P = .05.
Sixty-three patients with APBF were matched with 95 patients with no APBF. At the pre–stage 2 catheterization, APBF patients had a larger left pulmonary artery diameter (z score, 0.1 vs −0.8; P < .042). Patients with APBF had shorter cardiopulmonary bypass time (57.0 vs 79.0 minutes), shorter duration of mechanical ventilation (14.1 vs 17.4 hours), and shorter hospital length of stay (5.0 vs 7.0 days) at stage 2 palliation (P < .05). In the multivariable Cox regression analysis, patients with hypoplastic pulmonary arteries (z scores < −2; adjusted hazard ratio, 9.17) and patients with chromosomal abnormalities/genetic syndrome (adjusted hazard ratio, 4.03) were at increased risk for poor outcomes (P < .05). During the follow-up period, there was no significant difference in risk of the composite poor outcome and long-term survival between groups.
SV patients with APBF had shorter cardiopulmonary bypass time, duration of mechanical ventilation, and hospital length of stay after stage 2 palliation. Patients with hypoplastic pulmonary arteries or chromosomal abnormalities/genetic syndromes had increased risk for poor outcomes. Maintaining APBF has better short-term outcomes, but there are no long-term hemodynamic or survival benefits.
Percutaneous management of challenging complex resistive targets in interventional pediatric cardiology
2022, Debulking in Cardiovascular Interventions and Revascularization Strategies: Between a Rock and the Heart
This chapter will detail background information, preprocedure strategic considerations, appropriate imaging tools, and decisions for selection of interventional technologies and techniques when performing catheter-based interventions in pediatric-aged and young adult patients in and through calcified cardiac tissues and other resistive conditions. Both congenital lesions and those following surgical interventions are discussed.
Stenting for pulmonary artery stenosis complicated by univentricular physiology: Subanalysis of JPIC stent survey
2014, Journal of Cardiology
Citation Excerpt :
PS complicating UVP may lead to various morbidities, including changes in the pulmonary vascular bed, increased central venous pressure, ascites, pleural effusion, and protein losing enteropathy. The long-term outcome after bidirectional Glenn and Fontan procedures depends on pulmonary artery growth [5]. In these patients, the pulmonary circulation lacks a pumping chamber and pulmonary blood flow is driven by systemic venous pressure.
Stent implantation is an important treatment option for pulmonary artery stenosis (PS), even if complicated by univentricular physiology (UVP). However, there is paucity of evidence concerning not only its hemodynamic and morphologic indications but also on markers for its optimal target attainment in UVP. The purpose of this study was to evaluate the acute outcome and factors associated with efficacy of stenting for PS complicating UVP.
A subanalysis was performed using the data of the Japanese Society of Pediatric Interventional Cardiology (JPIC) stent survey. We analyzed the morphologic and hemodynamic data of 11 patients with UVP who underwent stenting for PS. We defined “a 50% increase in the minimum lumen diameter (MLD)” as “morphologically effective,” and “an achievement of 0 mmHg pressure gradient” as “hemodynamically effective.” We analyzed the success rate for each criterion and determined factors which may have contributed to hemodynamic effectiveness.
Stenting was morphologically effective in all patients, while it was hemodynamically effective in 6/11 (55%). The percent diameter stenosis after stenting was significantly lower in the “hemodynamically effective” group (2.5 ± 5.5% vs 19.6 ± 13.1%, p = 0.017). The cutoff value of percent diameter stenosis after stenting to “hemodynamically effective” was 14.6%; the sensitivity was 80% and the specificity was 100% (area under the curve 0.825, p = 0.021).
The percent diameter stenosis after stenting significantly contributed to achieving a “0 mmHg” pressure gradient, while in order to achieve a “0 mmHg” pressure gradient, the residual percent diameter stenosis should be less than around 15%.
Absence of Pulmonary Artery Growth After Fontan Operation and Its Possible Impact on Late Outcome
2009, Annals of Thoracic Surgery
Citation Excerpt :
There are at present no approved strategies to maintain the “biventricular circuit energetics” in the univentricular flow system. It has been claimed that an additional aortopulmonary shunt could be beneficial for PA growth in patients with bidirectional cavopulmonary shunt [7, 25]. Whether similar strategies such as an aortopulmonary shunt or an arteriovenous fistula could be beneficial for Fontan patients needs further clinical investigation.
The purpose of this study was to evaluate the development of the pulmonary arteries (PAs) after Fontan operation in children at long term.
Thirty-five patients in whom Fontan operation was performed at median age of 4.2 years (range, 1.5 to 16.1 years) underwent angiographic measurements of the central and lower lobe PA diameter before Fontan operation and during the median follow-up of 4.6 years (range, 1.4 to 15.1 years). The median patient age at follow-up was 8.6 years (range, 3.4 to 27.2 years). Body surface area–dependent PA index and lower lobe index were calculated, and preoperative and follow-up values were compared. A correlation between the PA indices and the duration of the follow-up as well as between PA indices and the outcome was investigated.
Although percentile parallel somatic development of the children could be documented by body surface area measurements (0.62 to 0.93 m² during the follow-up; p < 0.001), the PA showed no gain in diameter at all. The PA index and lower lobe index (preoperative median, 261 and 138 mm²/m², respectively) decreased significantly during the follow-up period (median, 177 and 109 mm²/m²;p < 0.001). The lowest PA index was noted in patients who had the longest follow-up (R = 0.5; p = 0.009). We found a correlation between a low PA index and an unfavorable Fontan outcome (n = 10, p = 0.002).
Growth of PAs after Fontan operation is clearly reduced despite somatic growth. This phenomenon may lead to an increase in pulmonary vascular resistance and could be a limit for optimal Fontan circulation in grown children in the long term.
Staged Hybrid Left Pulmonary Artery Rehabilitation in Post-Fontan Left Pulmonary Artery Hypoplasia
2007, Annals of Thoracic Surgery
Persistent Antegrade Pulmonary Blood Flow Post-Glenn Does Not Alter Early Post-Fontan Outcomes in Single-Ventricle Patients
2007, Annals of Thoracic Surgery
Citation Excerpt :
In our study, although group 1 had persistently higher oxygen saturations (86% versus 81%) and decreased hemoglobin levels (15.4 versus 16.6 mg/dL) at the time of Fontan compared with group 2, this did not lead to decreased postoperative morbidity. Third, most of the controversy over the maintenance of pulsatile APBF after BDG surrounds the potential enhancement of PA growth after BDG [4, 5, 17–20]. We demonstrated that those without APBF did not enjoy the same degree of PA growth as those with APBF.
The bidirectional Glenn cavopulmonary anastomosis (BDG) represents the standard interim procedure in treatment of patients with single-ventricle physiology. Anterograde pulmonary blood flow (APBF) maintained after BDG has been shown both to improve and to complicate postoperative clinical course. We studied its effects on outcome after BDG and eventual Fontan completion.
From November 1995 to November 2005, 60 patients underwent BDG and Fontan. All patients had APBF from the ventricle to the pulmonary artery at time of BDG. In group 1 (n = 39) APBF was maintained after BDG, whereas APBF was interrupted at BDG in group 2 (n = 21). Cardiac catheterization data, interstage morbidity, and postoperative outcome variables were recorded.
Pre-BDG hemodynamics differed only in that the mean pulmonary artery pressure was higher in group 2 (17.0 ± 4.4 mm Hg) than in group 1 (13.8 ± 4.5 mm Hg; p = 0.03). There were no differences between groups 1 and 2 in BDG outcome variables. At pre-Fontan catheterization, group 1 had higher mean pulmonary artery pressure (13.3 versus 10.9 mm Hg, p = 0.01), arterial oxygen saturation (85.8 versus 80.9%, p = 0.0001), and fewer collateral vessels were coil embolized than in group 2 (0.9 versus 1.6, p = 0.02). Mean ventricular end-diastolic pressure was similar between groups. The Nakata index in group 1 remained stable from pre-BDG to pre-Fontan (348 versus 391, p = 0.24), but it decreased in group 2 (375 versus 227, p = 0.046).
Patients with anterograde pulmonary blood flow after BDG had a modest increase in pulmonary artery growth and arterial oxygen saturations, and decreased collateral vessel formation. This did not, however, confer additional benefit on outcome after BDG or on eventual Fontan completion.

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¹: Dr. Slavik's address is: Wessex Cardiothoracic Centre, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, United Kingdom.

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Brief reportInfluence of bidirectional superior cavopulmonary anastomosis on pulmonary arterial growth

Abstract

Am J Cardiol

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Cavopulmonary anastomosis as long-term palliation for patients with tricuspid atresia

Eur J Cardiothorac Surg

Brief report
Influence of bidirectional superior cavopulmonary anastomosis on pulmonary arterial growth