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Azhar A, Eid R, Elakaby A, Abdelsalam M, Al-Ata J, Alkhushi N, Bahaidarah S, Zaher Z, Maghrabi K, Noaman N, Abdelmohsen G. Outcomes of bidirectional Glenn surgery done without prior cardiac catheterization. Egypt Heart J 2022; 74:57. [PMID: 35925522 PMCID: PMC9352820 DOI: 10.1186/s43044-022-00296-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 07/27/2022] [Indexed: 11/25/2022] Open
Abstract
Background Cardiac catheterization is usually done routinely in patients with univentricular hearts before palliative Bidirectional Glenn (BDG) surgery. The objective of this study was to compare the outcomes of patients with physiological univentricular hearts and restrictive pulmonary flow that did not undergo routine cardiac catheterization before BDG with the patients that did have cardiac catheterization done. We retrospectively reviewed the data of all patients with single ventricle physiology and restrictive pulmonary blood flow who underwent BDG surgery from January 2016 till December 2020. Patients were divided into two groups: the catheterization and the non-catheterization groups. Results Out of 93 patients, 25 (27%) underwent BDG surgery without prior cardiac catheterization. The median age of patients was ten months, interquartile range (IQR) was 5–18 months. Tricuspid atresia represented 36% of the non-catheterization group, while unbalanced atrioventricular septal defect and hypoplastic left heart syndrome represented 19% and 17.6% of the catheterization group. No patients in the catheterization group were excluded from further BDG surgery based on the catheterization data. Moreover, no significant differences were found between the patients' groups regarding the length of hospital stay, length of intensive care unit stay, postoperative oxygen saturation, or survival (P = 0.266, P = 0.763, P = 0.543, P = 0456). Conclusions Although pre-BDG cardiac catheterization is the routine and standard practice, in certain situations, some patients with single ventricle physiology and restrictive pulmonary blood flow may go directly to BDG without cardiac catheterization if noninvasive imaging is satisfactory on a case-by-case basis and according to center experience. Pre-BDG catheterization could be reserved for patients with limited echocardiographic studies, high-risk patients, or those indicated for catheter intervention before BDG surgery.
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Management of patients with single ventricle physiology across the lifespan: contributions from magnetic resonance and computed tomography imaging. Can J Cardiol 2022; 38:946-962. [DOI: 10.1016/j.cjca.2022.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/27/2021] [Accepted: 01/02/2022] [Indexed: 12/12/2022] Open
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Risk factors for morbidity and mortality after a bidirectional Glenn shunt in Northern Thailand. Gen Thorac Cardiovasc Surg 2020; 69:451-457. [PMID: 32783183 DOI: 10.1007/s11748-020-01461-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 08/04/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Owing to the evolution of surgical techniques, the survival rate of patients undergoing a bidirectional Glenn shunt has improved. However, the morbidity and mortality are still high. The aims of this study were to determine the survival rate and risk factors influencing the morbidity and mortality in patients with a functional univentricular heart after a bidirectional Glenn shunt. METHODS One hundred and fifty-one patients who had undergone a bidirectional Glenn operation were enrolled. Early worse outcomes were defined as postoperative death within 30 days and a hospital stay ≥ 30 days. RESULTS The median age was 7.1 years (range 0.3-26 years). The median age at the time of the Glenn operation was 2.2 years (range 0.2-15.9 years). The survival rates of patients at 1-, 5-, 10- and 15-year after the Glenn operation were 89%, 79%, 75%, and 72%, respectively. The predictors for the mortality were preoperative mean pulmonary artery pressure ≥ 17 mmHg, preoperative pulmonary vascular resistance index ≥ 3.1 Wood Units·m2 and atrioventricular valve regurgitation. In addition, the independent predictors of an early worse outcome included preoperative mean pulmonary artery pressure ≥ 17 mmHg and diaphragmatic paralysis. CONCLUSION The presence of preoperative atrioventricular valve regurgitation, preoperative mean pulmonary artery pressure ≥ 17 mmHg, preoperative pulmonary vascular resistance index ≥ 3.1 Wood Units·m2, or diaphragmatic paralysis were found to be independent risk factors requiring the good patients' selection for the Glenn operation and early aggressive management of the diaphragmatic paralysis for reducing morbidity to ensure successful candidature for Fontan completion.
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Frommelt PC, Hu C, Trachtenberg F, Baffa JM, Boruta RJ, Chowdhury S, Cnota JF, Dragulescu A, Levine JC, Lu J, Mercer-Rosa L, Miller TA, Shah A, Slesnick TC, Stapleton G, Stelter J, Wong P, Newburger JW. Impact of Initial Shunt Type on Echocardiographic Indices in Children After Single Right Ventricle Palliations. Circ Cardiovasc Imaging 2019; 12:e007865. [PMID: 30755054 DOI: 10.1161/circimaging.118.007865] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Heart size and function in children with single right ventricle (RV) anomalies may be influenced by shunt type at the Norwood procedure. We sought to identify shunt-related differences during early childhood after staged surgical palliations using echocardiography. Methods We compared echocardiographic indices of RV, neoaortic, and tricuspid valve size and function at 14 months, pre-Fontan, and 6 years in 241 subjects randomized to a Norwood procedure using either the modified Blalock-Taussig shunt or RV-to-pulmonary-artery shunt. Results At 6 years, the shunt groups did not differ significantly in any measure except for increased indexed neoaortic area in the modified Blalock-Taussig shunt. RV ejection fraction improved between pre-Fontan and 6 years in the RV-to-pulmonary artery shunt group but was stable in the modified Blalock-Taussig shunt group. For the entire cohort, RV diastolic and systolic size and functional indices were improved at 6 years compared with earlier measurements, and indexed tricuspid and neoaortic annular area decreased from 14 months to 6 years. The prevalence of ≥moderate tricuspid and neoaortic regurgitation was uncommon and did not vary by group or time period. Diminished RV ejection fraction at the 14-month study was predictive of late death/transplant; the hazard of late death/transplant when RV ejection fraction was <40% was tripled (hazard ratio, 3.18; 95% CI, 1.41-7.17). Conclusions By 6 years after staged palliation, shunt type has not impacted RV size and function, and RV and valvar size and function show beneficial remodeling. Poor RV systolic function at 14 months predicts worse late survival independent of the initial shunt type. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT00115934.
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Affiliation(s)
- Peter C Frommelt
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Hospital of Wisconsin, Milwaukee (P.C.F., J.S.).,Department of Pediatrics, Division of Pediatric Cardiology, Medical College of Wisconsin, Milwaukee (P.C.F., J.S.)
| | - Chenwei Hu
- Department of Pediatrics, Division of Pediatric Cardiology, New England Research Institutes, Waterford, MA (C.H., F.T.)
| | - Felicia Trachtenberg
- Department of Pediatrics, Division of Pediatric Cardiology, New England Research Institutes, Waterford, MA (C.H., F.T.)
| | - Jeanne Marie Baffa
- Department of Pediatrics, Division of Pediatric Cardiology, The Nemours Cardiac Center, Wilmington, DE (J.M.B.)
| | - Richard J Boruta
- Department of Pediatrics, Division of Pediatric Cardiology, Duke University Hospital, Durham, NC (R.J.B.)
| | - Shahryar Chowdhury
- Department of Pediatrics, Division of Pediatric Cardiology, Medical University of South Carolina, Charleston (S.C.)
| | - James F Cnota
- Department of Pediatrics, Division of Pediatric Cardiology, Cincinnati Children's Hospital and Medical Center, OH (J.F.C.)
| | - Andreea Dragulescu
- Department of Pediatrics, Division of Pediatric Cardiology, Hospital of Sick Children, Toronto, Canada (A.D.)
| | - Jami C Levine
- Department of Pediatrics, Division of Pediatric Cardiology, Boston Children's Hospital, Harvard Medical School, MA (J.C.L., J.W.N.)
| | - Jimmy Lu
- Department of Pediatrics, Division of Pediatric Cardiology, University of Michigan Medical School, Ann Arbor (J.L.)
| | - Laura Mercer-Rosa
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Hospital of Philadelphia, University of Pennsylvania Medical School (L.M.-R.)
| | - Thomas A Miller
- Department of Pediatrics, Division of Pediatric Cardiology, Primary Children's Medical Center, University of Utah, Salt Lake City (T.A.M.)
| | - Amee Shah
- Department of Pediatrics, Division of Pediatric Cardiology, Morgan Stanley Children's Hospital of New York-Presbyterian (A.S.).,Department of Pediatrics, Division of Pediatric Cardiology, Columbia College of Physicians and Surgeons, New York, NY (A.S.)
| | - Timothy C Slesnick
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Healthcare of Atlanta, Emory University, Atlanta, GA (T.C.S.)
| | - Gary Stapleton
- Department of Pediatrics, Division of Pediatric Cardiology, John Hopkins All Children's Health Institute, Baltimore, MD (G.S.)
| | - Jessica Stelter
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Hospital of Wisconsin, Milwaukee (P.C.F., J.S.).,Department of Pediatrics, Division of Pediatric Cardiology, Medical College of Wisconsin, Milwaukee (P.C.F., J.S.)
| | - Pierre Wong
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Hospital Los Angeles, CA (P.W.)
| | - Jane W Newburger
- Department of Pediatrics, Division of Pediatric Cardiology, Boston Children's Hospital, Harvard Medical School, MA (J.C.L., J.W.N.)
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Meza JM, Hickey E, McCrindle B, Blackstone E, Anderson B, Overman D, Kirklin JK, Karamlou T, Caldarone C, Kim R, DeCampli W, Jacobs M, Guleserian K, Jacobs JP, Jaquiss R. The Optimal Timing of Stage-2-Palliation After the Norwood Operation. Ann Thorac Surg 2017; 105:193-199. [PMID: 28847537 DOI: 10.1016/j.athoracsur.2017.05.041] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 05/11/2017] [Accepted: 05/12/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND The effect of the timing of stage-2-palliation (S2P) on survival through single ventricle palliation remains unknown. This study investigated the optimal timing of S2P that minimizes pre-S2P attrition and maximizes post-S2P survival. METHODS The Congenital Heart Surgeons' Society's critical left ventricular outflow tract obstruction cohort was used. Survival analysis was performed using multiphase parametric hazard analysis. Separate risk factors for death after the Norwood and after S2P were identified. Based on the multivariable models, infants were stratified as low, intermediate, or high risk. Cumulative 2-year, post-Norwood survival was predicted. Optimal timing was determined using conditional survival analysis and plotted as 2-year, post-Norwood survival versus age at S2P. RESULTS A Norwood operation was performed in 534 neonates from 21 institutions. The S2P was performed in 71%, at a median age of 5.1 months (IQR: 4.3 to 6.0), and 22% died after Norwood. By 5 years after S2P, 10% of infants had died. For low- and intermediate-risk infants, performing S2P after age 3 months was associated with 89% ± 3% and 82% ± 3% 2-year survival, respectively. Undergoing an interval cardiac reoperation or moderate-severe right ventricular dysfunction before S2P were high-risk features. Among high-risk infants, 2-year survival was 63% ± 5%, and even lower when S2P was performed before age 6 months. CONCLUSIONS Performing S2P after age 3 months may optimize survival of low- and intermediate-risk infants. High-risk infants are unlikely to complete three-stage palliation, and early S2P may increase their risk of mortality. We infer that early referral for cardiac transplantation may increase their chance of survival.
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Affiliation(s)
- James M Meza
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario
| | - Edward Hickey
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario
| | - Brian McCrindle
- Division of Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario
| | - Eugene Blackstone
- Division of Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Brett Anderson
- Division of Cardiology, Morgan-Stanley Children's Hospital/New York Presbyterian Hospital, New York, New York
| | - David Overman
- Division of Pediatric Cardiovascular Surgery, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - James K Kirklin
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Tara Karamlou
- Division of Thoracic and Cardiovascular Surgery, Phoenix Children's Hospital, Phoenix, Arizona
| | - Christopher Caldarone
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario
| | - Richard Kim
- Division of Cardiothoracic Surgery, Los Angeles Children's Hospital, Los Angeles, California
| | - William DeCampli
- Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, Florida
| | - Marshall Jacobs
- Division of Cardiac Surgery, Johns Hopkins Heart and Vascular Institute, Baltimore, Maryland
| | - Kristine Guleserian
- Division of Cardiovascular Surgery, Niklaus Children's Hospital, Miami, Florida
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Robert Jaquiss
- Division of Pediatric Cardiothoracic Surgery, Children's Medical Center, Dallas, Texas.
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Meza JM, Hickey EJ, Blackstone EH, Jaquiss RDB, Anderson BR, Williams WG, Cai S, Van Arsdell GS, Karamlou T, McCrindle BW. The Optimal Timing of Stage 2 Palliation for Hypoplastic Left Heart Syndrome: An Analysis of the Pediatric Heart Network Single Ventricle Reconstruction Trial Public Data Set. Circulation 2017; 136:1737-1748. [PMID: 28687711 DOI: 10.1161/circulationaha.117.028481] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 06/26/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND In infants requiring 3-stage single-ventricle palliation for hypoplastic left heart syndrome, attrition after the Norwood procedure remains significant. The effect of the timing of stage 2 palliation (S2P), a physician-modifiable factor, on long-term survival is not well understood. We hypothesized that an optimal interval between the Norwood and S2P that both minimizes pre-S2P attrition and maximizes post-S2P survival exists and is associated with individual patient characteristics. METHODS The National Institutes of Health/National Heart, Lung, and Blood Institute Pediatric Heart Network Single Ventricle Reconstruction Trial public data set was used. Transplant-free survival (TFS) was modeled from (1) Norwood to S2P and (2) S2P to 3 years by using parametric hazard analysis. Factors associated with death or heart transplantation were determined for each interval. To account for staged procedures, risk-adjusted, 3-year, post-Norwood TFS (the probability of TFS at 3 years given survival to S2P) was calculated using parametric conditional survival analysis. TFS from the Norwood to S2P was first predicted. TFS after S2P to 3 years was then predicted and adjusted for attrition before S2P by multiplying by the estimate of TFS to S2P. The optimal timing of S2P was determined by generating nomograms of risk-adjusted, 3-year, post-Norwood, TFS versus the interval from the Norwood to S2P. RESULTS Of 547 included patients, 399 survived to S2P (73%). Of the survivors to S2P, 349 (87%) survived to 3-year follow-up. The median interval from the Norwood to S2P was 5.1 (interquartile range, 4.1-6.0) months. The risk-adjusted, 3-year, TFS was 68±7%. A Norwood-S2P interval of 3 to 6 months was associated with greatest 3-year TFS overall and in patients with few risk factors. In patients with multiple risk factors, TFS was severely compromised, regardless of the timing of S2P and most severely when S2P was performed early. No difference in the optimal timing of S2P existed when stratified by shunt type. CONCLUSIONS In infants with few risk factors, progressing to S2P at 3 to 6 months after the Norwood procedure was associated with maximal TFS. Early S2P did not rescue patients with greater risk factor burdens. Instead, referral for heart transplantation may offer their best chance at long-term survival. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT00115934.
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Affiliation(s)
- James M Meza
- From Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada (J.M.M., E.J.H., W.G.W., S.C., G.S.V.A.); Departments of Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B.); Division of Pediatric Cardiothoracic Surgery, Children's Medical Center, Dallas, TX (R.D.B.J.); Division of Pediatric Cardiology, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Division of Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, AZ (T.K.); and Division of Pediatric Cardiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada (B.W.M.).
| | - Edward J Hickey
- From Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada (J.M.M., E.J.H., W.G.W., S.C., G.S.V.A.); Departments of Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B.); Division of Pediatric Cardiothoracic Surgery, Children's Medical Center, Dallas, TX (R.D.B.J.); Division of Pediatric Cardiology, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Division of Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, AZ (T.K.); and Division of Pediatric Cardiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada (B.W.M.)
| | - Eugene H Blackstone
- From Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada (J.M.M., E.J.H., W.G.W., S.C., G.S.V.A.); Departments of Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B.); Division of Pediatric Cardiothoracic Surgery, Children's Medical Center, Dallas, TX (R.D.B.J.); Division of Pediatric Cardiology, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Division of Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, AZ (T.K.); and Division of Pediatric Cardiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada (B.W.M.)
| | - Robert D B Jaquiss
- From Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada (J.M.M., E.J.H., W.G.W., S.C., G.S.V.A.); Departments of Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B.); Division of Pediatric Cardiothoracic Surgery, Children's Medical Center, Dallas, TX (R.D.B.J.); Division of Pediatric Cardiology, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Division of Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, AZ (T.K.); and Division of Pediatric Cardiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada (B.W.M.)
| | - Brett R Anderson
- From Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada (J.M.M., E.J.H., W.G.W., S.C., G.S.V.A.); Departments of Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B.); Division of Pediatric Cardiothoracic Surgery, Children's Medical Center, Dallas, TX (R.D.B.J.); Division of Pediatric Cardiology, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Division of Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, AZ (T.K.); and Division of Pediatric Cardiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada (B.W.M.)
| | - William G Williams
- From Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada (J.M.M., E.J.H., W.G.W., S.C., G.S.V.A.); Departments of Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B.); Division of Pediatric Cardiothoracic Surgery, Children's Medical Center, Dallas, TX (R.D.B.J.); Division of Pediatric Cardiology, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Division of Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, AZ (T.K.); and Division of Pediatric Cardiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada (B.W.M.)
| | - Sally Cai
- From Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada (J.M.M., E.J.H., W.G.W., S.C., G.S.V.A.); Departments of Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B.); Division of Pediatric Cardiothoracic Surgery, Children's Medical Center, Dallas, TX (R.D.B.J.); Division of Pediatric Cardiology, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Division of Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, AZ (T.K.); and Division of Pediatric Cardiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada (B.W.M.)
| | - Glen S Van Arsdell
- From Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada (J.M.M., E.J.H., W.G.W., S.C., G.S.V.A.); Departments of Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B.); Division of Pediatric Cardiothoracic Surgery, Children's Medical Center, Dallas, TX (R.D.B.J.); Division of Pediatric Cardiology, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Division of Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, AZ (T.K.); and Division of Pediatric Cardiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada (B.W.M.)
| | - Tara Karamlou
- From Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada (J.M.M., E.J.H., W.G.W., S.C., G.S.V.A.); Departments of Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B.); Division of Pediatric Cardiothoracic Surgery, Children's Medical Center, Dallas, TX (R.D.B.J.); Division of Pediatric Cardiology, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Division of Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, AZ (T.K.); and Division of Pediatric Cardiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada (B.W.M.)
| | - Brian W McCrindle
- From Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON, Canada (J.M.M., E.J.H., W.G.W., S.C., G.S.V.A.); Departments of Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clinic, OH (E.H.B.); Division of Pediatric Cardiothoracic Surgery, Children's Medical Center, Dallas, TX (R.D.B.J.); Division of Pediatric Cardiology, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center (B.R.A.); Division of Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, AZ (T.K.); and Division of Pediatric Cardiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada (B.W.M.)
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Meza JM, Jaquiss RDB, Anderson BR, Moga MA, Kirklin JK, Sarris G, Williams WG, McCrindle BW. Current Practices in the Timing of Stage 2 Palliation. World J Pediatr Congenit Heart Surg 2017; 8:135-141. [PMID: 28329463 DOI: 10.1177/2150135116677253] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Mortality through single-ventricle palliation remains high and the effect of the timing of stage 2 palliation (S2P) is not well understood. We investigated current practice patterns in the timing of S2P across two professional societies and compared them to actual practice patterns from two databases of patients who underwent S2P. METHODS A ten-question survey was distributed to the members of the Congenital Heart Surgeons' Society (CHSS) and the European Congenital Heart Surgeons' Association (ECHSA). Results were summarized using descriptive statistics. Surgeon-reported preferences were compared to clinical data from the CHSS Critical Left Ventricular Outflow Tract Obstruction (LVOTO) Registry and the Pediatric Heart Network Single Ventricle Reconstruction (SVR) database. RESULTS Overall, 38% (88 of 232) of surgeons from 74 institutions responded, of which 70% (62 of 88) were CHSS members and 30% (26 of 88) were ECHSA members. Surgeons reported performing S2P at a median of five months after stage 1 (interquartile range [IQR]: 4.5-6), with no difference between CHSS and ECHSA surgeons. Surgeons reported performing nonelective S2P at a median of 4.5 months after stage 1 (IQR: 3.5-5.5), again with no difference by society. No difference existed between the surgeon-reported preferences and patient data in the Critical LVOTO and SVR databases for the timing of elective (5 vs 5.1 vs 5.3 months, P = .19) or nonelective S2P (4.5 vs 4.6 vs 4.2 months, P = .06). CONCLUSION There was a remarkable lack of variation in surgeon preferences regarding the timing of S2P. This may represent a natural standardization of practice across congenital heart surgery, which is notable, given the current lack of guidelines regarding the timing of S2P.
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Affiliation(s)
- James M Meza
- 1 John W. Kirklin/David Ashburn Fellow, Congenital Heart Surgeons' Society Data Center, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Robert D B Jaquiss
- 2 Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Brett R Anderson
- 3 Division of Cardiology, Department of Pediatrics, Morgan-Stanley Children's Hospital/New York Presbyterian Hospital, New York, NY, USA
| | - Michael-Alice Moga
- 4 Division of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - James K Kirklin
- 5 Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - George Sarris
- 6 Department of Pediatric Heart Surgery, IASO Children's Hospital, Athens, Greece
| | - William G Williams
- 7 Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Brian W McCrindle
- 8 Division of Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
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8
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Nichay NR, Gorbatykh YN, Kornilov IA, Soynov IA, Ivantsov SM, Gorbatykh AV, Ponomarev DN, Bogachev-Prokophiev AV, Karaskov AM. Bidirectional cavopulmonary anastomosis with additional pulmonary blood flow: good or bad pre-Fontan strategy. Interact Cardiovasc Thorac Surg 2017; 24:582-589. [PMID: 28093463 DOI: 10.1093/icvts/ivw429] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 11/23/2016] [Indexed: 11/12/2022] Open
Abstract
Objectives This study aimed to evaluate the influence of preserved additional pulmonary blood flow (APBF) on survival after bidirectional cavopulmonary shunt (BCPS) and completion of Fontan circulation. Methods From March 2003 and April 2015, 156 patients with a single ventricle underwent BCPS. After performing propensity score analysis (1:1) for the entire sample, 50 patients with APBF (APBF group) were matched with 50 patients without APBF (no-APBF group). Results Age ( P = 0.90), sex ( P = 0.57), weight ( P = 0.75), single ventricle morphology ( P = 0.87), type of neonatal palliative procedure ( P = 0.52), saturation ( P = 0.35), ejection fraction ( P = 0.90), Nakata index ( P = 0.70) and mean pulmonary artery pressure ( P = 0.72) were not significantly different between the groups. No significant survival difference was demonstrated ( P = 0.54). One and 4-year survival rates were both 89.1% ± 4.6% in the APBF group and 87.2% ± 4.9% and 83.4% ± 5.9%, respectively, in the no-APBF group. There was no significant difference in rates of Fontan completion ( P = 0.24), which was achieved in 22 patients from the APBF group (55.0%) and 26 patients from the no-APBF group (65.0%). However, Fontan completion occurred significantly earlier in the no-APBF group ( P < 0.01). In this group, Fontan procedure was performed before 36 months of inter-stage period in 45.9% ± 8.5% of cases (95% CI 31.0-63.7%) compared to only 13.3 ± 5.6% (95% CI 5.8-29.1%) in the APBF group. Conclusions Our study demonstrates that APBF does not affect survival after BCPS or Fontan completion rate. APBF allows postponing the Fontan procedure without a negative effect on clinical status.
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Affiliation(s)
- Nataliya R Nichay
- Department of Congenital Heart Disease, Research Institute of Circulation Pathology, Novosibirsk, Russian Federation
| | - Yuriy N Gorbatykh
- Department of Congenital Heart Disease, Research Institute of Circulation Pathology, Novosibirsk, Russian Federation
| | - Igor A Kornilov
- Department of Anesthesiology, Research Institute of Circulation Pathology, Novosibirsk, Russian Federation
| | - Ilya A Soynov
- Department of Congenital Heart Disease, Research Institute of Circulation Pathology, Novosibirsk, Russian Federation
| | - Sergey M Ivantsov
- Department of Congenital Heart Disease, Research Institute of Circulation Pathology, Novosibirsk, Russian Federation
| | - Artem V Gorbatykh
- Department of Congenital Heart Disease, Research Institute of Circulation Pathology, Novosibirsk, Russian Federation
| | - Dmitriy N Ponomarev
- Department of Anesthesiology, Research Institute of Circulation Pathology, Novosibirsk, Russian Federation
| | | | - Alexander M Karaskov
- Department of Congenital Heart Disease, Research Institute of Circulation Pathology, Novosibirsk, Russian Federation
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9
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Ravishankar C, Gerstenberger E, Sleeper LA, Atz AM, Affolter JT, Bradley TJ, Gaynor JW, Goldstein BH, Henderson HT, Jacobs JP, Lewis AB, Dunbar-Masterson C, Menon SC, Pemberton VL, Petit CJ, Pike NA, Pizarro C, Schumacher KR, Williams IA, Newburger JW. Factors affecting Fontan length of stay: Results from the Single Ventricle Reconstruction trial. J Thorac Cardiovasc Surg 2015; 151:669-675.e1. [PMID: 26519244 DOI: 10.1016/j.jtcvs.2015.09.061] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 08/20/2015] [Accepted: 09/04/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND In the Single Ventricle Reconstruction trial, infants with hypoplastic left heart syndrome (HLHS) who received a right-ventricle-to-pulmonary-artery shunt (RVPAS) versus a modified Blalock-Taussig shunt (MBTS) had lower early postoperative mortality, but more complications at 14 months. We explored the effect of shunt type and other patient, medical, and surgical factors on postoperative length of stay (LOS) after the Fontan operation. METHODS Fontan postoperative course was ascertained from medical record review. Cox proportional hazards modeling was used to identify factors associated with LOS. RESULTS Of 327 subjects who underwent Fontan, 323 were analyzed (1 death, 1 biventricular repair, 2 with missing data). Median age and weight at Fontan were 2.8 years (interquartile range [IQR]: 2.3, 3.4) and 12.7 kg (IQR: 11.4, 14.1), respectively. Fontan type was extracardiac in 55% and lateral tunnel in 45%; 87% were fenestrated. The RVPAS and MBTS subjects had similar LOS (median 11 days [IQR: 9, 18] vs 10 days [IQR: 9, 13]; P = .23). Independent risk factors for longer LOS were treatment center (P < .01), LOS at stage II (hazard ratio [HR] 1.02 for each additional day; P < .01), and pre-Fontan complications (HR 1.03 for each additional complication; P = .04). Use of deep hypothermic circulatory arrest at Fontan (HR 0.64; P = .02) was independently associated with shorter LOS. When center was excluded from the model, pre-Fontan complications and use of circulatory arrest were no longer significant; instead, older age at stage II (HR 1.08 for each additional month; P = .01) predicted longer LOS. In 254 subjects who had a pre-Fontan echocardiogram, at least moderate tricuspid regurgitation was independently associated with longer LOS, both with center (HR 1.72; P < .01) and without center in the model (HR 1.49; P = .02). CONCLUSIONS In this multicenter prospective cohort of subjects with HLHS, Norwood shunt type was not associated with Fontan LOS. Rather, global measures of earlier medical complexity indicate greater likelihood of longer LOS after the Fontan operation.
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Affiliation(s)
- Chitra Ravishankar
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pa.
| | | | | | - Andrew M Atz
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Jeremy T Affolter
- Department of Critical Care Medicine, The Children's Hospital of Wisconsin, Milwaukee, Wis
| | - Timothy J Bradley
- Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Bryan H Goldstein
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Jeffrey P Jacobs
- Division of Cardiothoracic Surgery, Congenital Heart Institute of Florida, St Petersburg, Fla
| | - Alan B Lewis
- Department of Pediatrics, Children's Hospital of Los Angeles, Los Angeles, Calif
| | | | - Shaji C Menon
- University of Utah, Department of Pediatrics, Salt Lake City, Utah
| | - Victoria L Pemberton
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md
| | | | - Nancy A Pike
- Department of Nursing, University of California, Los Angeles, Los Angeles, Calif
| | - Christian Pizarro
- Division of Cardiothoracic Surgery, Alfred I. DuPont Hospital for Children, Wilmington, Del
| | - Kurt R Schumacher
- Department of Pediatrics, University of Michigan Health Center, Ann Arbor, Mich
| | - Ismee A Williams
- Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
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10
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Fate of ventricular and valve performance following early bidirectional Glenn procedure after Norwood operation controlled for hypoplastic left heart syndome anatomic subtype. Pediatr Cardiol 2014; 35:332-43. [PMID: 24126954 DOI: 10.1007/s00246-013-0780-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 08/14/2013] [Indexed: 10/26/2022]
Abstract
The Norwood operation (NO) with a right ventricle (RV)-to-pulmonary artery (PA) shunt (NRVPA) is reportedly associated with early hemodynamic advantage. Shunt strategy has been implicated in ventricular function. Outcomes after NRVPA compared with classic procedure as part of a strategy involving early bidirectional Glenn (BDG) procedure were analyzed with reference to RV, tricuspid, and neoaortic valve performance. Between January 2005 and December 2010, 128 neonates with hypoplastic left heart syndrome (HLHS) underwent NO. Controlled for aortic/mitral stenosis (AS-MS) subtype, 28 patients underwent NRVPA (group A), and 26 patients had classic procedure (group B). The patients with a non-HLHS single-ventricle anatomy and those who had undergone a hybrid approach for HLHS were excluded from the study. The mean age at NO was 6.8 ± 3.5 days in group A and 6.9 ± 3.6 days in group B. Transthoracic echocardiographic evaluation (TTE) after NO (TTE-1) at the midinterval between NO and BDG (TTE-2), before BDG (TTE-3), before Fontan (TTE-4), and at the last follow-up evaluation (TTE-5) was undertaken. Cardiac catheterization was used to assess hemodynamic parameters before the Glenn and Fontan procedures. The operative, interstage, and pre-Fontan survival rates for AS-MS after NO were respectively 88.1 % (90.3 % in group A vs. 84.7 % in group B; p = 0.08), 82.5 % (82.7 % in group A vs. 81.8 % in group B; p = 0.9), and 80.7 % (79.5 % in group A vs. 81.8 % in group B; p = 0.9). The median follow-up period was 39.6 months (interquartile range 2.7-4.9 months). The RV global function, mid- and longitudinal indexed dimensions, fractionated area change before BDG (TTE-1, TTE-2, TTE-3) and after BDG (TTE-4, TTE-5), and right ventricular end-diastolic pressure did not differ statistically between the groups (p > 0.05). No statistically significant difference in tricuspid or neoaortic intervention was found between the groups (p > 0.05). Controlled for the AS-MS HLHS subtype, shunt strategy showed no midterm survival or hemodynamic (ventricular or valve) impact. At midterm, the follow-up need for neoaortic or tricuspid valve surgical intervention was not affected by shunt selection. The structural ventricular adaptation after reversal of shunt physiology was irrespective of shunt strategy.
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11
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Misumi Y, Hoashi T, Kagisaki K, Kitano M, Kurosaki K, Shiraishi I, Yagihara T, Ichikawa H. Long-term outcomes of common atrioventricular valve plasty in patients with functional single ventricle. Interact Cardiovasc Thorac Surg 2013; 18:259-65. [PMID: 24336698 DOI: 10.1093/icvts/ivt508] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Common atrioventricular valve (CAVV) regurgitation is widely known as a risk factor for mortality and Fontan completion in patients with functional single ventricle. Hence, we reviewed our surgical experience with CAVV plasty in Fontan candidates. METHODS Staged Fontan strategy and extracardiac total cavopulmonary connection as Fontan modification were our principal approaches in 1995. Since then, 38 consecutive Fontan candidates (21 males, median weight at operation was 7.0 kg and median age was 17 months old) underwent CAVV plasty. Right atrial isomerism was associated with 24 patients. The initial CAVV plasty was performed before inter-stage bidirectional Glenn (BDG) in 3 patients, at BDG in 23, before Fontan in 4 and during Fontan in 8. Since 1995, the modified Alfieri technique with a tailed, expanded, polytetrafluoroethylene tube as a bridging strip was the procedure for repair and 27 patients underwent the procedure. The mean follow-up period was 7.1 years (range 0-17 years). RESULTS Actuarial survival and freedom from CAVV replacement rates at 1, 5 and 10 years were 81, 70 and 67% and 89, 85 and 75%, respectively. Seven patients ultimately underwent CAVV replacement with one death. Twenty-three of the 38 patients completed Fontan operation (61%). Association with total anomalous pulmonary venous connection (P= 0.01) and CAVV plasty before BDG (P= 0.05) were risk factors for mortality. CONCLUSIONS CAVV plasty for patients with functional single ventricle is still challenging; however, the aggressive and repeated surgical intervention may contribute to provide better life-prognosis. The ventricular volume unloading effect of BDG without additional pulmonary blood flow or Fontan operation did not contribute to maintain CAVV function. Therefore, there would not be any hesitation for CAVV replacement to control CAVVR in the setting of systemic ventricular failure. Although the statistically significant therapeutic superiority of the modified Alfieri technique was not shown so far, further follow-up may reveal the advantage of this easy and simple technique.
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Affiliation(s)
- Yusuke Misumi
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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12
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Risk factors for prolonged length of stay after the stage 2 procedure in the single-ventricle reconstruction trial. J Thorac Cardiovasc Surg 2013; 147:1791-8, 1798.e1-4. [PMID: 24075564 DOI: 10.1016/j.jtcvs.2013.07.063] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 07/05/2013] [Accepted: 07/26/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND The single-ventricle reconstruction trial randomized patients with single right ventricle lesions to a modified Blalock-Taussig or right ventricle-to-pulmonary artery shunt at the Norwood. This analysis describes outcomes at the stage 2 procedure and factors associated with a longer hospital length of stay (LOS). METHODS We examined the association of shunt type with stage 2 hospital outcomes. Cox regression and bootstrapping were used to evaluate risk factors for longer LOS. We also examined characteristics associated with in-hospital death. RESULTS There were 393 subjects in the analytic cohort. Median stage 2 procedure hospital LOS (8 days; interquartile range [IQR], 6-14 days), hospital mortality (4.3%), transplantation (0.8%), median ventilator time (2 days; IQR, 1-3 days), median intensive care unit LOS (4 days; IQR, 3-7 days), number of additional cardiac procedures or complications, and serious adverse events did not differ by shunt type. Longer LOS was associated (R(2) = 0.26) with center, longer post-Norwood LOS (hazard ratio [HR], 1.93 per log day; P < .001), nonelective timing of the stage 2 procedure (HR, 1.78; P < .001), and pulmonary artery (PA) stenosis (HR, 1.56; P < .001). By univariate analysis, nonelective stage 2 (65% vs 32%; P = .009), moderate or greater atrioventricular valve (AVV) regurgitation (75% vs 24%; P < .001), and AVV repair (53% vs 9%; P < .001) were among the risk factors associated with in-hospital death. CONCLUSIONS Norwood LOS, PA stenoses, and nonelective stage 2 procedure, but not shunt type, are independently associated with longer LOS. Nonelective stage 2 procedure, moderate or greater AVV regurgitation, and need for AVV repair are among the risk factors for death.
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Alsoufi B, Al-Wadai A, Khan M, Al-Ahmadi M, Kalloghlian A, Bulbul Z, Al-Fayyadh M, Al-Halees Z. Outcomes of Damus-Kaye-Stansel anastomosis at time of cavopulmonary connection in single ventricle patients at risk of developing systemic ventricular outflow tract obstruction. Eur J Cardiothorac Surg 2013; 45:77-82. [DOI: 10.1093/ejcts/ezt251] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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14
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Univentricular heart and Fontan staging: analysis of factors impacting on body growth. Eur J Cardiothorac Surg 2012; 41:e139-45. [DOI: 10.1093/ejcts/ezs194] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Umezu K, Harada Y, Sakamoto T, Maekawa Y, Takigiku K, Yasukochi S. Fontan completion after Norwood with bidirectional Glenn shunt: their haemodynamics and pulmonary artery configuration. Interact Cardiovasc Thorac Surg 2012; 15:204-8. [PMID: 22572411 DOI: 10.1093/icvts/ivs138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES We ranked the haemodynamics and pulmonary artery (PA) configurations of Norwood with bidirectional Glenn shunt (NW-G) patients among the other staged Fontan completion (conventional) patients in this study. METHODS Between August 2001 and April 2010, 91 consecutive patients completed staged Fontan operations. Among them, NW-G was performed in 11. RESULTS There was no operative or late death except in one case which resulted from a reoperation after Fontan completion. Although the age at bidirectional Glenn (BDG) and Fontan completion was younger in NW-G (4.2 vs. 10.9 months, P < 0.01, and 2.3 vs. 3.3 years, P < 0.01), the interval between BDG and Fontan completion was not significantly different in these groups (23.6 vs. 28.0 months, P = 0.71). On Fontan completion, the extracardiac conduit size was significantly different (16.4 vs. 17.7 mm, P < 0.01). However, the pulmonary artery size (PA index) and the PA pressure were not significantly different (165.4 vs. 205.1 mm(2)/m(2), P = 0.23, and 13.4 vs. 11.0 mmHg, P = 0.08). Particularly in hypoplastic left heart syndrome patients, the PA index was not significantly different between these groups (165.4 vs. 174.9 mm(2)/m(2), P = 0.59). CONCLUSIONS The NW-G patients could have a subsequent Fontan completion with good results. There was no significant difference with respect to Fontan completion.
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Affiliation(s)
- Kentaro Umezu
- Division of Cardiovascular Surgery, Nagano Children's Hospital, Nagano, Japan.
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Gérelli S, Boulitrop C, Van Steenberghe M, Maldonado D, Bojan M, Raisky O, Sidi D, Vouhé PR. Bidirectional cavopulmonary shunt with additional pulmonary blood flow: a failed or successful strategy? Eur J Cardiothorac Surg 2012; 42:513-9. [PMID: 22368190 DOI: 10.1093/ejcts/ezs053] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES In patients with single ventricle physiology, Fontan circulation is considered as the optimal surgical approach, although it entails a growing incidence of late complications. It has been speculated that the association of bidirectional cavopulmonary shunt (BCPS) and additional pulmonary blood flow (APBF) might provide long-lasting palliation. The present study was undertaken to assess the long-term outcome of this strategy. METHODS A group of 70 patients with single ventricle physiology, who underwent BCPS with APBF between 1990 and 2000, were reviewed retrospectively. Median age at operation was 2 years (range: 0.1-27 years). Unilateral BCPS was performed in 60 patients (86%), bilateral BCPS in 9 and the Kawashima procedure in 1. APBF was provided through antegrade pulmonary outflow tract in 43 patients (61%) and by aortopulmonary shunt in 27 (39%). Two patients died early and three were lost to follow-up. Mean follow-up of the 65 remaining patients was 13.5 ± 4 years. End-points were death, need for heart transplantation (HTx) or Fontan completion and functional outcome. RESULTS Five patients died (two after HTx, three from ventricular failure); overall actuarial survival was 89 ± 4% at 15 years. Six patients underwent HTx (one after Fontan completion) with two early deaths and no late mortality. Fifty-one patients underwent Fontan completion (11 with additional palliative procedures before completion); there was no early or late mortality following Fontan completion; one patient underwent HTx. Among the remaining six patients with BCPS and APBF, two were not suitable for Fontan completion and four remained suitable. Overall, clinical failure (mortality, HTx, unsuitability for Fontan completion) occurred in 13 patients (19%). Risk factors for clinical failure were older age at BCPS (P = 0.01) and postoperative complications after BCPS (P = 0.001). Considering late mortality, HTx and Fontan completion as strategic failures, the actuarial freedom from these events was 20 ± 5% at 10 years. CONCLUSIONS BCPS with APBF approach: (i) fails as a strategy for definitive palliation, (ii) provides a high survival rate, (iii) does not preclude a successful Fontan completion and (iv) may delay the long-term deleterious consequences of Fontan circulation. Palliation by BCPS with APBF should be achieved early in life.
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Affiliation(s)
- Sébastien Gérelli
- Department of Pediatric Cardiac Surgery, University Paris Descartes, Sorbonne Paris Cité and Sick Children Hospital, Paris, France
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Alsoufi B, Manlhiot C, Awan A, Alfadley F, Al-Ahmadi M, Al-Wadei A, McCrindle BW, Al-Halees Z. Current outcomes of the Glenn bidirectional cavopulmonary connection for single ventricle palliation. Eur J Cardiothorac Surg 2012; 42:42-8; discussion 48-9. [DOI: 10.1093/ejcts/ezr280] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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