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Current outcomes of the bi-directional cavopulmonary anastomosis in single ventricle patients: analysis of risk factors for morbidity and mortality, and suitability for Fontan completion

Published online by Cambridge University Press:  23 February 2015

Katrien François ,
Kristof Vandekerckhove ,
Katya De Groote ,
Joseph Panzer ,
Daniel De Wolf ,
Hans De Wilde  and
Thierry Bové
Katrien François*
Affiliation:
Department of Congenital Cardiac Surgery, The Cardiac Centre, University Hospital Gent, Belgium
Kristof Vandekerckhove
Affiliation:
Department of Pediatric Cardiology, The Cardiac Centre, University Hospital Gent, Belgium
Katya De Groote
Affiliation:
Department of Pediatric Cardiology, The Cardiac Centre, University Hospital Gent, Belgium
Joseph Panzer
Affiliation:
Department of Pediatric Cardiology, The Cardiac Centre, University Hospital Gent, Belgium
Daniel De Wolf
Affiliation:
Department of Pediatric Cardiology, The Cardiac Centre, University Hospital Gent, Belgium
Hans De Wilde
Affiliation:
Department of Pediatric Cardiology, The Cardiac Centre, University Hospital Gent, Belgium
Thierry Bové
Affiliation:
Department of Congenital Cardiac Surgery, The Cardiac Centre, University Hospital Gent, Belgium
*
Correspondence to: K. François, MD, Department of Cardiac Surgery, University Hospital Gent, De Pintelaan 185, 9000 Gent, Belgium. Tel: +0032 9 332 47 00; Fax: +0032 9 332 38 82; E-mail: katrien.francois@ugent.be
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Abstract

Objectives

The bi-directional cavopulmonary anastomosis forms an essential staging procedure for univentricular hearts. This review aims to identify risk factors for morbidity, mortality, and suitability for Fontan completion.

Methods

A total of 114 patients undergoing cavopulmonary anastomosis between 1992 and 2012 were reviewed to assess primary – mortality and survival to Fontan completion – and secondary outcome endpoints – re-intubation, new drain, and ICU stay. Median age and weight were 8 months and 6.9 kg, respectively. In 83% of patients, 1–3 interventions had preceded. Norwood-type procedures became more prevalent over time.

Results

Extubation occurred after a median of 4 hours, median ICU stay was 2 days; 10 patients (8.8%) needed re-intubation and 18 received a new drain. Higher central venous pressure and transpulmonary gradient were risk factors for new drain insertion (p<0.01). Higher pre-operative pulmonary pressure correlated with increased inotropic support and prolonged intubation (p=0.01). Need for re-intubation was significantly affected by younger age at operation (p=0.01). Hospital and pre-Fontan mortality were 11.4 and 5.3%, respectively. Operative mortality was independently affected by younger age (p=0.013), lower weight (p=0.02), longer bypass time (p=0.04), and re-intubation (p=0.004). Interstage mortality was mainly influenced by moderate ventricular function (p=0.03); 82% of survivors underwent or are candidates for Fontan completion.

Conclusion

The cavopulmonary anastomosis remains associated with adverse outcomes. Age at operation decreases with rising prevalence of complex univentricular hearts. Considering the important impact of re-intubation on hospital mortality, peri-operative management should focus on optimising cardio-respiratory status. Once this selection step is taken, successful Fontan completion can be expected, provided that ventricular function is maintained.

Keywords

Congenital heart diseasesingle ventriclepaediatric cardiac surgerypost-operative management
Type
Original Articles
Information
Cardiology in the Young , Volume 26 , Issue 2 , February 2016 , pp. 288 - 297
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Copyright
© Cambridge University Press 2015 

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References

1. Masuda, M, Kado, H, Shiokawa, Y, et al. Clinical results of the staged Fontan procedure in high-risk patients. Ann Thorac Surg 1998; 65: 1721–1725.Google Scholar
2. Norwood, WI, Jacobs, ML. Fontan’s procedure in two stages. Am J Surg 1993; 166: 548–551.CrossRefGoogle ScholarPubMed
3. Jonas, RA. Indications and timing for the bidirectional Glenn shunt versus the fenestrated Fontan circulation. J Thorac Cardiovasc Surg 1994; 108: 522–524.Google Scholar
4. Reddy, VM, McElhinney, DB, Moore, P, Haas, GS, Hanley, FL. Outcomes after bidirectional cavopulmonary shunt in infants less than 6 months old. J Am Coll Cardiol 1997; 29: 1365–1370.CrossRefGoogle Scholar
5. Bove, EL. Current status of staged reconstruction for hypoplastic left heart syndrome. Pediatr Cardiol 1998; 19: 308–315.CrossRefGoogle ScholarPubMed
6. Alejos, JC, Williams, RG, Jarmakani, JM, et al. Factors influencing survival in patients undergoing the bidirectional Glenn anastomosis. Am J Cardiol 1995; 75: 1048–1050.CrossRefGoogle ScholarPubMed
7. Frommelt, MA, Frommelt, PC, Berger, S, et al. 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
8. Kogon, BE, Plattner, C, Leong, T, Simsic, J, Kirshbom, PM, Kanter, KR. The bidirectional Glenn operation: a risk factor analysis for morbidity and mortality. J Thorac Cardiovasc Surg 2008; 136: 1237–1242.CrossRefGoogle ScholarPubMed
9. Cnota, JF, Allen, KR, Colan, S, et al. Superior cavopulmonary anastomosis timing and outcomes in infants with single ventricle. J Thorac Cardiovasc Surg 2013; 145: 1288–1296.CrossRefGoogle ScholarPubMed
10. Friedman, KG, Salvin, JW, Wypij, D, et al. Risk factors for failed staged palliation after bidirectional Glenn in infants who have undergone stage one palliation. Eur J Cardiothorac Surg 2011; 40: 1000–1006.Google Scholar
11. Karl, TR. The bidirectional cavopulmonary shunt for hypoplastic left heart syndrome. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2001; 4: 58–70.Google Scholar
12. François, K, Bové, T, Panzer, J, et al. Univentricular heart and Fontan staging: analysis of factors impacting on body growth. Eur J Cardiothorac Surg 2012; 41: e139–e145.Google Scholar
13. 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.Google Scholar
14. Tan, AM, Iyengar, AJ, Donath, S, et al. Fontan completion rate and outcomes after bidirectional cavo-pulmonary shunt. Eur J Cardiothorac Surg 2010; 38: 59–65.Google Scholar
15. Cruz, DN, Antonelli, M, Fumagalli, R, et al. Early use of polymyxin B hemoperfusion in abdominal septic shock: the EUPHAS randomized controlled trial. JAMA 2009; 301: 2445–2452.Google Scholar
16. Douglas, WI, Goldberg, CS, Mosca, RS, Law, IH, Bove, EL. Hemi-Fontan procedure for hypoplastic left heart syndrome: outcome and suitability for Fontan. Ann Thorac Surg 1999; 68: 1361–1368.CrossRefGoogle ScholarPubMed
17. Bradley, SM, Mosca, RS, Hennein, HA, Crowley, DC, Kulik, TJ, Bove, EL. Bidirectional superior cavopulmonary connection in young infants. Circulation 1996; 94 (Suppl 9): II5–II11.Google Scholar
18. Slavik, Z, Lamb, RK, Webber, SA, et al. Bidirectional superior cavopulmonary anastomosis: how young is too young? Heart 1996; 75: 78–82.CrossRefGoogle Scholar
19. Chen, Q, Tulloh, R, Caputo, M, Stoica, S, Kia, M, Parry, AJ. Does the persistence of pulsatile antegrade pulmonary blood flow following bidirectional Glenn procedure affect long term outcome? Eur J Cardiothorac Surg 2015; 47: 154–158.CrossRefGoogle ScholarPubMed
20. Yamada, K, Roques, X, Elia, N, et al. The short- and mid-term results of bidirectional cavopulmonary shunt with additional source of pulmonary blood flow as definitive palliation for the functional single ventricular heart. Eur J Cardiothorac Surg 2000; 18: 683–689.CrossRefGoogle Scholar
21. Henaine, R, Vergnat, M, Mercier, O, et al. Hemodynamics and arteriovenous malformations in cavopulmonary anastomosis: the case for residual antegrade pulsatile flow. J Thorac Cardiovasc Surg 2013; 146: 1359–1365.CrossRefGoogle ScholarPubMed
22. Srivastava, D, Preminger, T, Lock, JE, et al. Hepatic venous blood and the development of pulmonary arteriovenous malformations in congenital heart disease. Circulation 1995; 92: 1217–1222.Google Scholar
23. Agarwal, HS, Churchwell, KB, Doyle, TP, et al. Inhaled nitric oxide use in bidirectional Glenn anastomosis for elevated Glenn pressures. Ann Thorac Surg 2006; 81: 1429–1435.Google Scholar
24. Adatia, I, Atz, AM, Wessel, DL. Inhaled nitric oxide does not improve systemic oxygenation after bidirectional superior cavopulmonary anastomosis. J Thorac Cardiovasc Surg 2005; 129: 217–219.CrossRefGoogle Scholar
25. Siehr, SL, Norris, JK, Bushnell, JA, et al. Home monitoring program reduces interstage mortality after the modified Norwood procedure. J Thorac Cardiovasc Surg 2014; 147: 718–723.Google Scholar
26. Hehir, DA, Cooper, DS, Walters, EM, Ghanayem, NS. Feeding, growth, nutrition, and optimal interstage surveillance for infants with hypoplastic left heart syndrome. Cardiol Young 2011; 21 (Suppl 2): 59–64.Google Scholar
27. Alsoufi, B, Manlhiot, C, Awan, A, et al. Current outcomes of the Glenn bidirectional cavopulmonary connection for single ventricle palliation. Eur J Cardiothorac Surg 2012; 42: 42–49.Google Scholar