Hostname: page-component-586b7cd67f-tf8b9 Total loading time: 0 Render date: 2024-11-24T12:29:13.587Z Has data issue: false hasContentIssue false

Possible sources of right-to-left shunting in patients following a total cavopulmonary connection

Published online by Cambridge University Press:  19 August 2008

Gernot Buheitel*
Affiliation:
Department of Pediatric Cardiology and Department of Cardiovascular SurgeryUniversity Erlangen-Nürnberg, Germany
Michael Hofbeck
Affiliation:
Department of Pediatric Cardiology and Department of Cardiovascular SurgeryUniversity Erlangen-Nürnberg, Germany
Ursula Tenbrink
Affiliation:
Department of Pediatric Cardiology and Department of Cardiovascular SurgeryUniversity Erlangen-Nürnberg, Germany
Georg Leipold
Affiliation:
Department of Pediatric Cardiology and Department of Cardiovascular SurgeryUniversity Erlangen-Nürnberg, Germany
Jürgen v.d. Emde
Affiliation:
Department of Pediatric Cardiology and Department of Cardiovascular SurgeryUniversity Erlangen-Nürnberg, Germany
Helmut Singer
Affiliation:
Department of Pediatric Cardiology and Department of Cardiovascular SurgeryUniversity Erlangen-Nürnberg, Germany
*
Priv. Doz. Dr med. Gernot Buheitel, Universiteit Kinderklinik, Loschgestraáe 15, D-91054 Erlangen, Germany. Tel: 9131 3750; Fax: 9131 3113

Abstract

Despite a good haemodynamic result, many children have amildly decreased arterial oxygen saturation following a total cavopulmonary connection. Our study was performed to determine possible mechanisms of right-to-left shunting in these patients. We performed elective cardiac catheterization in 19 children at a mean interval of 3.6 years following a total cavopulmonary connection. The intrapulmonary right-to-left shunt, the intracardiac right-to-left shunt and the total right-to-left shunt were calculated under mechanical ventilation with 100% oxygen. The intrapulmonary right-to-left shunt was 10.8±3.5% of the pulmonary blood flow, and the total right-to left shunt accounted for 18.9±5.2% of the systemic blood flow. The intracardiac right-to-left shunt in patients with no relevant venovenous collaterals or leaks in the atrial tunnel was calculated at 6.4±3.0% of the systemic blood flow, while the intracardiac right-to-left shunt in patients with relevant collaterials or leaks accounted for 13.0±5.9% of the systemic blood flow. Since intrapulmonary arteriovenous fistulas were not demonstrated angiographically in any of our patients, the intrapulmonary right-to-left shunt is probably due to low ratios of perfusion to ventilation in some pulmonary segments. The intracafdiac right-to-left shunt was due to leaks across the interatrial baffle, collaterals between stystemic and pulmonary veins, and to the coronary sinus draining to the pulmonary venous atrium.

Type
Original Articles
Copyright
Copyright © Cambridge University Press 1998

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1.Wolff, GDie künstliche Beatmung auf Intensivstationen Springer Berlin, 1975.CrossRefGoogle Scholar
2.Bernstein, HS, Brook, MM, Silverman, NH, Bristow, J. Early development of Pulmonary arteriovenous fistulae in children following cavopulmonary shunt. circulation 1994; 90 (part2): 1421.Google Scholar
3.Bernstein, HS, Brook, MM, Silverman, NH, Bristow, JDevelopment of pulmonary arteriovenous fistulae in children after cavopulmonary shunt. Circulation 1995; 92(suppl2): II- 309314.CrossRefGoogle ScholarPubMed
4.Bernstein, HS, Ursell, PC, Brook, MM, Hanley, FC, Silverman, NH, Bristow, J, Fulminant development of pulmonary arteriovenous fistulas in an infant after total cavopulmonary shunt. Pediatt Cardiol 1996; 17: 4650.CrossRefGoogle Scholar
5.Srivastava, D, Preminger, T, Lock, JE, Mandell, VKeane, JF, Mayer, JE Jr, Kozakewich, H, Spevak, PJ. Hepatic venous blood and the development of pulmonary arteriovenous malformation in congenital heart disease. Circulation 1995; 92: 12171222.CrossRefGoogle ScholarPubMed
6.Matsushita, T, Matsuda, H, Ogawa, M, Ohno, K, Sano, T, Nakano, S, Shimazaki, Y, Nakahara, K, Ariswa, J, Kozuka, T, Kawashima, Y, Yabuuchi, H. Assessment of the intrapulmonary ventilation-perfrsion distribution after the Footan procedur for complex cardiac anomalies: relation to pulmonary haemodynamics. J Am coll Cardiol 1990; 15: 842848.CrossRefGoogle Scholar
7.Gatzoulis, MA, Shinebourne, EA, Redington, AN, Rigby, ML, Ho, SY,Shore, DF. Increasing cyanosis early cavopulmonary connection caused by abnormal systemic venous channels. Br Heart J 1995; 73: 182186.CrossRefGoogle ScholarPubMed
8.Hayes, AM, Burrows, PE, Benson, LN. An unusual cause of cyanosis after the modified Fontan procedur-closure of venous communications between the coronary sinus and left atrium by transcatheter techniques. Cardiol Young 1994; 4: 172174.CrossRefGoogle Scholar
9.stümper, O, Wright, JGC, Sadiq, M, De Giovanni, JV. Late systemic desaturation after total cavopulmonary shunt operations. Br Heart J 1995; 74: 282286.CrossRefGoogle ScholarPubMed
10.Hsu, H, Nykanen, DG, Williams, WG, Freedom, RM, Benson, LN. Right to left interatrial communications after the modified Fontan procedure: identification and management with transcatheter occlusion. Br Heart J 1995; 74: 548552.CrossRefGoogle ScholarPubMed
Fernandez-Martorell, P, Sklansky, MS, Lucas, VW, kashani, IA, Cocalis, MW, Jamieson, SW, Rothman, A. Accessory hepatic vein to pulmonary venous atrium as a cause of cyanosis after the Fontan operation. Am J Cardiol 1996; 77: 13861387.CrossRefGoogle ScholarPubMed
Rao, IM, Swanson, JS, Hovaguimian, H, McIrvin, DM, King, DH, Furnary, AP, Livermore, J, Starr, A. Intrahepatic steal after Fontan operation with partial hepatic exclusion. J Thorac Cardiovasc Surg 1995; 109: 180181.CrossRefGoogle ScholarPubMed
Slavik, Z, Lamb, RK, Webber, SA, Delaney, DJ, Salmon, AP. A rare cause of profound cyanosis after Kawashima modification of bidirectional cavopulmonary anastomosis. Ann Thorac Surg v 1995;60: 435437.CrossRefGoogle ScholarPubMed
Wilson, DG, Wisheart, JD, Stuart, AG. Systemic thromboembolish leading to myocardial infarction and strode after fenestrated total cavopulmonary connection. Br Heart J 1995; 73: 483485.CrossRefGoogle Scholar
Castaneda, AR, Bridges, ND. The Fontan operation with afenestrated patch rationale and results. Cardiol Young 1993; 3: 202206.CrossRefGoogle Scholar
Redington, AN, Rigby, ML. Transcatheter closure of interattial communications with a modified umbrella device. Br Heart J 1994; 3: 372377.CrossRefGoogle Scholar
Laschinger, JC, Redmond, JM, Cameron, DE, Kan, JS, Ringel, RE. Intermediate results of the extracardiac Fontan Procedure. Ann Thorc surg 1996; 62: 12611267.CrossRefGoogle ScholarPubMed
Jahangiri, M, Ross, DB, Redington, AN, Lincoln, c, Shinebourne, EA. Thromboembolism after the Fontan procedure and its modifications. Ann Thorac surg 1994; 58: 14091414.CrossRefGoogle ScholarPubMed
Hofbeck, M, singer, H, Bucheirtel, G, Sunnegardh, J, Emde, J.v.d.. Formation of thrombus in the residual pulmonary trunk and regulation of the pulmonary valve after total cavopulmonary connection. Cardiol Young 1997; 7:4449.CrossRefGoogle Scholar
Nierner, M, Nemes, C, Datenbuch der Internsivemedizin. Fischer, Stuttgart, 1979.Google Scholar
Redington, AN, Penny, D, Shinebourne, EA. Pulmonary blood flow after total cavopulmonary shunt. Br Heart J 1991; 12: 213217.CrossRefGoogle Scholar
Duplessis, AJ, Chang, AC, Wessel, DL, Lock, JE, Wernovsky, G, Newburger, JW, Mayer, JE Jr. Cerebrovascular accidents following the Fontan operation. Pediatr Neurol 1995;12:230236.CrossRefGoogle Scholar