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An institutional experience with the bidirectional cavopulmonary shunt: do we know enough about it?

Published online by Cambridge University Press:  19 August 2008

V. Mohan Reddy ,
Doff B. McElhinney ,
Phillip Moore ,
James Bristow ,
Gary S. Haas  and
Frank L. Hanley
V. Mohan Reddy*
Affiliation:
Divisions of Cardiothoracic Surgery. University of California, San Francisco, San Francisco, CA, USA
Doff B. McElhinney
Affiliation:
Divisions of Cardiothoracic Surgery. University of California, San Francisco, San Francisco, CA, USA
Phillip Moore
Affiliation:
Pediatric Cardiology, University of California, San Francisco, San Francisco, CA, USA
James Bristow
Affiliation:
Pediatric Cardiology, University of California, San Francisco, San Francisco, CA, USA
Gary S. Haas
Affiliation:
Divisions of Cardiothoracic Surgery. University of California, San Francisco, San Francisco, CA, USA
Frank L. Hanley
Affiliation:
Divisions of Cardiothoracic Surgery. University of California, San Francisco, San Francisco, CA, USA
*
V. Mohan Reddy, MD. Division of Cardiothoracic Surgery, University of California, San Francisco, 505 Parnassus Avenue, M593, San Francisco, CA 94143-0118. Tel: (415)476-3501 Fax: (415)476-9678
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Abstract

Background

The bidirectional cavopulmonary shunt has become a mainstay in the palliation of patients with a functionally single ventricle. Despite its usefulness, there are a number of concerns following its construction, including issues of timing, the development of pulmonary arteriovenous fistulas, and growth of the pulmonary arteries.

Methods

Between January 1990 and April 1996, we constructed a bidirectional cavopulmonary shunt in 123 patients. Median age at surgery was 9.4 months, and ranged from 24 days to 43 years. In 25 patients (20%), it was the first operative procedure. An auxiliary source of pulmonary blood flow was included in 72 patients (58%).

Results

Six patients (4.9%) died in the early postoperative period, and the overall early rate of failure (death or take-down) was 8.1%(n=10). By multivariate analysis, longer bypass time (p=0.012), age less than 1 month (p=0.03), and higher pulmonary vascular resistance (p = 0.043) were significant. Early reoperation was performed in 11 other patients to decrease (n=8) or increase (n=3) the amount of pulmonary blood flow. Early survivors were followed for a median of 15 months (range: 1 to 48 months), during which time 5 patients died and a Fontan circulation was completed in 30. Including early and late mortality, actuarial survival rates at 1 and 2 years were 91% and 88%, respectively. Among hospital survivors, the only significant predictor of poorer survival by Cox regression was age less than 2 months at the time of the initial cavopulmonary shunt (p=0.02). Atrioventricular valvar regurgitation was decreased after construction of the cavopulmonary shunt in 17 of the 28 patients (61%) in whom echocardiographic data were available to compare preoperative and postoperative status.

Conclusions

The bidirectional cavopulmonary shunt is a useful procedure in the early or intermediate term management of patients with a functionally univentricular heart. Much remains to be learned, nonetheless, about this unique physiologic system. The role of accessory pulmonary blood flow remains unclear, as does the use of the shunt as long-term palliation. Pulmonary arteriovenous fistulas are a serious concern, especially in young patients with heterotaxy syndrome (isomeric atrial appendages).

Keywords

Functionally single ventricleGlenn procedureextracardiac Fontan procedurepulmonary blood flow
Type
Original Articles
Information
Cardiology in the Young , Volume 7 , Issue 3 , July 1997 , pp. 284 - 293
Copyright
Copyright © Cambridge University Press 1997

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References

1.Hopkins, RA, Armstrong, BE, Serwer, GA, Peterson, RJ, Oldham, HN. Physiologic rationale for a bidirectional cavopulmonary shunt: A versatile component to the Fontan principle J Thorac Cardiovasc Surg 1985;90:391–398.CrossRefGoogle Scholar
2.Mazzera, E, Corno, A, Picardo, S, Di Donate, R, Marino, B, Costa, D, Marcelletti, C. Bidirectional cavopulmonary shunts: Clinical applications as staged or definitive palliation. Ann Thorac Surg 1989;47:415–420.CrossRefGoogle ScholarPubMed
3.Lamberti, JJ, Spicer, RL, Waldman, JD, Grehl, TM, Thomson, D, George, L, Kirkpatrick, SE, Mathewson, JW. The bidirectional cavopulmonary artery shunt J Thorac Cardiovasc Surg 1990;100:22–30.CrossRefGoogle Scholar
4.Bridges, ND, Jonas, RA, Mayer, JE, Flanagan, MF, Keane, JF, Castaneda, AR. Bidirectional cavopulmonary anastomosis as interim palliation for high-risk Fontan candidates: Early results. Circulation 1990;82[suppl IV]:IV-170–IV-176.Google ScholarPubMed
5.Albanese, SB, Carotti, A, Di Donate, RM, Mazzera, E, Troconis, CJ, Giannico, S, Picardo, S, Marcelletti, C. Bidirectional cavopulmonary anastomosis in patients under two years of age. J Thorac Cardiovasc Surg 1992; 104:904–909.CrossRefGoogle ScholarPubMed
6.Pridjian, AK, Mendelsohn, AM, Lupinetti, FM, Beekman, RH, Dick, M, Serwer, G, Bove, EL. Usefulness of the bidirectional Glenn procedure as staged reconstruction for the functional single ventricle. Am J Cardiol 1993;71:959–962.CrossRefGoogle ScholarPubMed
7.Hawkins, JA, Shaddy, RE, Day, RW, Sturtevant, JE, Orsmond, GS, McGough, EC. Mid-term results after bidirectional cavopulmonary shunts. Ann Thorac Surg 1993;56:833–837.CrossRefGoogle ScholarPubMed
8.Alejos, JC, Williams, RG, Jarmakani, JM, Galindo, AJ, Isabel-Jones, JB, Drinkwater, D, Laks, H, Kaplan, S. Factors influencing survival in patients undergoing the bidirectional Glenn anastomosis. Am J Cardiol 1995;75:1048–1050.CrossRefGoogle ScholarPubMed
9.Chang, AC, Hanley, FL, Wernovsky, G, Rosenfeld, HM, Wessel, DL, Jonas, RA, Mayer, JE, Lock, JE, Castaneda, AR. Early bidirectional cavopulmonary shunt in young infants: Postoperative course and early results. Circulation 1993;88[part 2]: 149–158.Google ScholarPubMed
10.Reddy, VM, Liddicoat, JR, Hanley, FL. Primary bidirectional superior cavopulmonary shunt in infants between 1 and 4 months of age. Ann Thorac Surg 1995;59:1120–1126.CrossRefGoogle ScholarPubMed
11.Muster, AJ, Zales, VR, Ilbawi, MN, Backer, CL, Duffy, CE, Mavroudis, C. Biventricular repair of hypoplastic right ventricle assisted by pulsatile bidirectional cavopulmonary anastomosis. J Thorac Cardiovasc Surg 1993;105:112–119.CrossRefGoogle ScholarPubMed
12.Miyaji, K, Shimada, M, Sekiguchi, A, Ishizawa, A, Isoda, T, Tsunemoto, M. Pulmonary atresia with intact ventricular septum: Long-term results of one and a half ventricle repair. Ann Thorac Surg 1995;60:1762–1764.CrossRefGoogle Scholar
13.VanArsdell, GS, Williams, WG, Maser, CM, Streitenberger, K, Rebeyka, IM, Coles, JG, Freedom, RM. Superior vena cava to pulmonary artery anastomosis: An adjunct to biventricular repair. J Thorac Cardiovasc Surg (In press)Google Scholar
14.Bernstein, HS, Brook, MM, Silverman, NH, Bristow, J. Development of pulmonary arteriovenous fistulae in children after cavopulmonary shunt. Circulation 1995;92[suppl II]:II-309–II-309.CrossRefGoogle ScholarPubMed
15.Triedman, JK, Bridges, ND, Mayer, JE, Lock, JE. Prevalence and risk factors for aortopulmonary collateral vessels after Fontan and bidirectional Glenn procedures. J Am Coll Cardiol 1993;22:207–215.CrossRefGoogle ScholarPubMed
16.Gatzoulis, MA, Shinebourne, EA, Redington, AN, Rigby, ML, Ho, SY, Shore, DF. Increasing cyanosis early after cavopulmonary connection caused by abnormal systemic venous channels. Br Heart J 1995;73:182–186.CrossRefGoogle ScholarPubMed
17.Mathur, M, Glenn, WWL. Long-term evaluation of cava-pulmonary artery anastomosis. Surgery 1973;74:899–916.Google ScholarPubMed
18.Cloutier, A, Ash, JM, Smallhorn, JF, Williams, WG, Trusler, GA, Rowe, RD, Rabinovitch, M. Abnormal distribution of pulmonary blood flow after the Glenn shunt or Fontan procedure: Risk of development of arteriovenous fistulae. Circulation 1985;72:471–479.CrossRefGoogle ScholarPubMed
19.Trusler, GA, Williams, WG, Cohen, AJ, Rabinovitch, M, Moes, CAF, Smallhorn, JF, Coles, JG, Lightfoot, NE, Freedom, RM. The cavopulmonary shunt: Evolution of a concept. Circulation 1990;82[suppl IV]:IV-131–IV-138.Google ScholarPubMed
20.Kopf, GS, Laks, H, Stansel, HC, Hellenbrand, WE, Kleinman, CS, Talner, NS. Thirty-year follow-up of superior vena cava-pulmonary artery (Glenn) shunts. J Thorac Cardiovasc Surg 1990;100:662–671.CrossRefGoogle ScholarPubMed
21.Mendelsohn, AM, Bove, EL, Lupinetti, FM, Crowley, DC, Lloyd, TR, Beekman, RH. Central pulmonary artery growth patterns after the bidirectional Glenn procedure. J Thorac Cardiovasc Surg 1994;107:1284–1290.CrossRefGoogle ScholarPubMed
22.Penny, DJ, Pawade, A, Wilkinson, JL, Karl, TR. Pulmonary artery size after bidirectional cavopulmonary connection. J Card Surg 1995;10:21–26.CrossRefGoogle ScholarPubMed
23.Salzer-Muhar, U, Marx, M, Ties, M, Proll, E, Wimmer, M. Doppler flow profiles in the right and left pulmonary artery in children with congenital heart disease and a bidirectional cavopulmonary shunt. Pediatr Cardiol 1994;15:302–307.CrossRefGoogle Scholar
24.Frommelt, MA, Frommelt, PC, Berger, S, Pelech, AN, Lewis, DA, Tweddell, JS, Litwin, SB. Does an additional source of pulmonary blood flow alter outcome after a bidirectional cavopulmonary shunt? Circulation 1995;92[suppl II]:II-240–II-244.CrossRefGoogle ScholarPubMed
25.Webber, SA, Horvath, P, LeBlanc, JG, Slavik, Z, Lamb, RK, Monro, JL, Reich, O, Hruda, J, Sandor, GGS, Keeton, BR, Salmon, AP. Influence of competitive pulmonary blood flow on the bidirectional superior cavopulmonary shunt: A multi-institutional study. Circulation 1995;92 [suppl II]:II-279–II-286.CrossRefGoogle ScholarPubMed
26.Mainwaring, RD, Lamberti, JJ, Uzark, K, Spicer, RL. Bidirectional Glenn: Is accessory pulmonary blood flow good or bad? Circulation 1995;92[suppl II]:II-294–II-297.CrossRefGoogle ScholarPubMed
27.Reddy, VM, McElhinney, DB, Moore, P, Petrossian, E, Hanley, FL. Pulmonary artery growth after bidirectional cavopulmonary shunt: Is there a cause for concern? J Thorac Cardiovasc Surg 1996;112:1180–1192.CrossRefGoogle Scholar
28.Marcelletti, C, Corno, A, Giannico, S, Marino, B. Inferior vena cava-pulmonary artery extracardiac conduit: A new form of right heart bypass. J Thorac Cardiovasc Surg 1990;100:228–232.CrossRefGoogle ScholarPubMed
29.Bernstein, HS, Ursell, PC, Hanley, FL, Brook, MM, Silverman, NH, Bristow, J. Fulminant development of pulmonary arteriovenous fistulae in an infant following total cavopulmonary shunt. Pediatr Cardiol 1996;17:46–50.CrossRefGoogle Scholar
30.Papagiannis, J, Kanter, RJ, Effman, EL, Pratt, PC, Marcille, R, Browning, IB, Armstrong, BE. Polysplenia with pulmonary arteriovenous malformations. Pediatr Cardiol 1993;14:127–129.CrossRefGoogle ScholarPubMed
31.Amodeo, A, Di Donate, RM, Carotti, A, Marino, B, Marcelletti, C. Pulmonary arteriovenous fistulas and polysplenia syndrome. (letter) J Thorac Cardiovasc Surg 1994;107:1378–1379.CrossRefGoogle ScholarPubMed