Original article
Pediatric cardiac
Bidirectional Glenn and Antegrade Pulmonary Blood Flow: Temporary or Definitive Palliation?

Presented at the Forty-second Annual Meeting of The Society of Thoracic Surgeons, Chicago, IL, Jan 30–Feb 1, 2006.
https://doi.org/10.1016/j.athoracsur.2008.01.013Get rights and content

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.

Section snippets

Patients and Methods

This study is a retrospective review of three joint institutions’ experience with BCPA and APBF (Azienda di rilievo nazionale e di alta specializzazione [ARNAS] Civico - Palermo, Italy; Ospedale S. Vincenzo - Taormina, Italy; Istituto G.Gaslini – Genova, Italy). The study was approved by the respective Ethics Committees of the three involved institutions.

Early Results After BCPA With APBF

No in-hospital death occurred. The median duration of mechanical ventilation was 21.3 hours (range, 8.7 to 120.4 hours).

The following complications were observed: prolonged pleural effusions (defined as drainage for more than ten days or the need for multiple drainage procedures) in 22 patients (8.9%); SVC syndrome (defined as the clinical manifestation of an obstructed SVC impeding the normal blood drainage from head, neck, and arms) in 24 patients (9.7%); pericardial effusions in 30 patients

Comment

Classic Fontan operation [11], knowledge of the pathophysiology of single ventricle, failure of ventricular septation [12], Glenn anastomosis [13], BCPA with APBF, staged approach [14], and extracardiac Fontan [15] are all essential moments of a long, hurdled itinerary in the search of the best orthoterminal surgical correction [16] with, possibly, a zero mortality.

Over the years, the experience with the Fontan operation has increased [17, 18, 19] and has opened the way to a much wider

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