Additional Pulmonary Blood Flow Has No Adverse Effect on Outcome After Bidirectional Cavopulmonary Anastomosis

doi:10.1016/j.athoracsur.2004.06.002

The Annals of Thoracic Surgery

Volume 79, Issue 1, January 2005, Pages 29-36

https://doi.org/10.1016/j.athoracsur.2004.06.002 Get rights and content

Background

Controversy continues over whether additional sources of pulmonary blood flow are beneficial in combination with a bidirectional cavopulmonary anastomosis. We have therefore assessed the effects of additional pulmonary blood flow on outcome after bidirectional cavopulmonary anastomosis.

Methods

From 1996 to 2000, 106 patients underwent bidirectional cavopulmonary anastomosis, either isolated (group 1, n = 54), or with additional pulmonary blood flow through the pulmonary artery (group 2, n = 30) or a Blalock-Taussig shunt (group 3, n = 22).

Results

Superior vena cava syndrome was more frequent in group 2 and less in groups 1 and 3 (p < 0.05). Low-output syndrome was more frequent in group 2 and less in group 3 (p = 0.01). Repeated-measures analysis of variance showed higher oxygen saturations with additional pulmonary blood flow (p < 0.05) and significant changes over time (p < 0.0001). Pulmonary pressures, systemic ventricular fractional shortening, end-diastolic diameter index, end-diastolic pressure, and atrioventricular valve regurgitation remained unaffected by additional pulmonary blood flow. Pulmonary artery pressures were lower in group 2 than 3 (p < 0.05). Fractional shortening (p < 0.05) and atrioventricular valve regurgitation (p < 0.0001) changed significantly over time. Fractional shortening showed a strong trend toward different changing patterns with or without additional pulmonary blood flow (p = 0.055), and atrioventricular valve regurgitation showed different changing patterns among the groups (p < 0.005). End-diastolic diameter and pulmonary artery dimensions, which were smaller than normal, remained unchanged. In logistic regression, smaller body surface area at bidirectional cavopulmonary anastomosis, single ventricle, and bidirectional cavopulmonary anastomosis with a Blalock-Taussig shunt were associated with early death. Actuarial survival including total cavopulmonary connection did not differ among groups (p = 0.96).

Conclusions

We conclude that additional pulmonary blood flow has no adverse effect on outcome after cavopulmonary anastomosis. Additional flow through the main pulmonary artery offers different advantages and disadvantages concerning perioperative complications and pulmonary artery growth compared with additional flow through a Blalock-Taussig shunt.

Section snippets

Material and Methods

We retrospectively reviewed the clinical and surgical records of 106 patients with single-ventricle physiology who underwent BDG between January 1996 and December 2000. Patients were divided into three groups according to the presence of APBF. In group 1 (n = 54), BDG was the only source of pulmonary flow; in group 2 (n = 30), APBF through a natively stenosed (n = 17) or previously banded main pulmonary artery (n = 13); and in group 3 (n = 22), APBF through a patent BT shunt was present.

Outcome After Bidirectional Cavopulmonary Anastomosis

Early outcome after BDG is summarized in Table 2. Six patients (5.7%) died in the early postoperative period, 3 in group 1 (5.5%) of cardiac failure, 1 in group 2 (3.3%) of sepsis, and 2 in group 3 (9.1%) of multiorgan and cardiac failure. Twelve patients (11.3%) had their BDG anastomosis taken down, and 3 of these died postoperatively. The BDG take-down became necessary because of high pulmonary artery pressures in 5, low oxygen saturations in 2, a combination of both in 2, low output failure

Comment

The bidirectional cavopulmonary anastomosis has become a standard intermediate step toward the Fontan circulation in the management of single-ventricle physiology 1, 4. The results of this analysis demonstrate no adverse effect of an additional source of pulmonary blood flow on the outcome of bidirectional cavopulmonary anastomosis.

Previous studies demonstrated higher oxygen saturation and lower hospital mortality rates among patients with APBF compared with patients in whom bidirectional

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Cited by (72)

Does leaving native antegrade pulmonary blood flow at the time of the superior cavopulmonary connection impact long-term outcomes after the Fontan?
2023, JTCVS Open
Antegrade pulmonary blood flow (APBF) may be left or eliminated at the time of the superior cavopulmonary connection (SCPC). Our aim was to assess the impact of leaving native APBF at the SCPC on long-term Fontan outcomes.
In the Australia and New Zealand Fontan Registry (1985-2021), 587 patients had pre-existing native APBF at the SCPC. At the SCPC, 302 patients had APBF eliminated (APBF⁻) and 285 patients had APBF maintained (APBF⁺). The incidence of Fontan failure (composite end point of Fontan takedown, transplant, plastic bronchitis, protein losing enteropathy and death) and atrioventricular (AV) valve repair/replacement post SCPC was compared between the 2 groups.
Sex, predominant-ventricle morphology, isomerism, primary diagnosis, and age/type of Fontan were similar between groups. APBF⁻ versus APBF⁺ had a higher incidence of arch obstruction/coarctation (17% vs 7%) and previous pulmonary artery band (54% vs 45%) and a lower rate of Fontan fenestration (27% vs 41%). The risk of Fontan failure was similar between the 2 groups (hazard ratio [HR], 1.01; 95% confidence interval [CI], 0.58-1.78; P = .96). The risk of AV-valve repair/replacement was greater in APBF⁺ versus APBF– (HR, 2.32; CI, 1.13-4.75; P = .022). The risk of AV-valve repair/replacement remained after adjustment for arch obstruction/coarctation, previous pulmonary artery band and Fontan fenestration (HR, 2.27; CI, 1.07-4.81; P = .033).
Maintaining APBF at the time of the SCPC does not impact the risk of Fontan failure but may increase the incidence of AV-valve repair and/or replacement post-SCPC.
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.
Influence of Antegrade Pulmonary Blood Flow on Outcomes of Superior Cavopulmonary Connection
2022, Annals of Thoracic Surgery
We sought to characterize short- and long-term outcomes after superior cavopulmonary connection (SCPC) in children eligible for inclusion of antegrade pulmonary blood flow (APBF) in the SCPC circuit, exploring whether maintaining APBF was associated with outcomes.
This was a retrospective cohort study of patients with single-ventricle heart disease and APBF who underwent SCPC at our center between January 1, 2000, and September 30, 2017. Patients were divided into 2 groups: APBF eliminated (APBF−), and APBF maintained (APBF+) at the time of SCPC.
Of 149 patients, 108 (72.5%) were in APBF− and 41 (27.5%) were in APBF+. Of those in APBF+, 5 (12.2%) subsequently had APBF eliminated after SCPC. Patients in APBF+ had a higher prevalence of chest tube duration >10 days and underwent more interventions during the post-SCPC hospitalization (1.9% vs 12%; P = .008 for both) but had shorter surgical support times at SCPC (P < .0001). There were no differences in post-SCPC intensive care unit or hospital length of stay. During the study period, 82 patients (76%) in APBF− and 22 patients (54%) in APBF+ underwent Fontan completion. Patients in APBF+ had a greater weight gain from SCPC to Fontan (6.7 [1.8-22] kg vs 8.15 [4.4-20.6] kg; P = .012) and a shorter hospital length of stay after Fontan (9 [4-107] days vs 7.5 [4-14] days; P = .044).
Short-term morbidity associated with maintaining APBF at the time of SCPC is modest, but longer term outcomes suggest potential benefits in those in whom APBF can be successfully maintained.
Device Occlusion of Native Pulmonary Blood Flow After Cavopulmonary Anastomosis With Persistent Pleural Effusions
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Factors associated with mortality or transplantation versus Fontan completion after cavopulmonary shunt for patients with tricuspid atresia
2022, Journal of Thoracic and Cardiovascular Surgery
Tricuspid atresia with normally related great vessels (TA) is considered the optimal substrate for the Fontan pathway. The factors associated with death or transplantation after cavopulmonary shunt (CPS) are underappreciated. We aimed to determine factors associated with CPS–Fontan interstage death/transplantation versus transition to Fontan in TA.
A total of 417 infants younger than 3 months of age with TA were enrolled (January 1999 to February 2020) from 40 institutions into the Congenital Heart Surgeons' Society TA cohort. Parametric competing risk methodology was used to determine factors associated with the competing end points of death/transplantation without Fontan completion, and transition to Fontan.
CPS was performed in 382 patients with TA; of those, 5% died or underwent transplantation without transition to Fontan and 91% transitioned to Fontan by 5 years after CPS. Prenatal diagnosis (hazard ratio [HR], 0.74; P < .001) and pulmonary artery band (PAB) at CPS (HR, 0.50; P < .001) were negatively associated with Fontan completion. Preoperative moderate or greater mitral valve regurgitation (HR, 3.0; P < .001), concomitant mitral valve repair (HR, 11.0; P < .001), PAB at CPS (HR, 3.0; P < .001), postoperative superior vena cava interventions (HR, 9.0; P < .001), and CPS takedown (HR, 40.0; P < .001) were associated with death/transplantation.
The mortality rate after CPS in patients with TA is notable. Those with preoperative mitral valve regurgitation remain a high-risk group. PAB at the time of CPS being associated with both increased risk of death and decreased Fontan completion may represent a deleterious effect of antegrade pulmonary blood flow in the CPS circulation.
Commentary: Flowers against nonflowers
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Original articleCardiovascularAdditional Pulmonary Blood Flow Has No Adverse Effect on Outcome After Bidirectional Cavopulmonary Anastomosis

Background

Methods

Results

Conclusions

Section snippets

Material and Methods

Outcome After Bidirectional Cavopulmonary Anastomosis

Comment

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Cardiovasc Surg

J Am Coll Cardiol

Use of the bidirectional Glenn procedure in the presence of forward flow from the ventricles to the pulmonary arteries

Circulation

Bidirectional cavopulmonary anastomosis as interim palliation for high–risk Fontan candidates: early results

Circulation

Original article
Cardiovascular
Additional Pulmonary Blood Flow Has No Adverse Effect on Outcome After Bidirectional Cavopulmonary Anastomosis