The real fate of pulmonary arteries after bidirectional superior cavopulmonary anastomosis: is there a need for concern?

Risk Factors and Outcome of Pulmonary Artery Stenting After Bidirectional Cavopulmonary Connection (BDCPC) in Single Ventricle Circulation

After bidirectional cavopulmonary connection (BDCPC) central pulmonary arteries (PAs) of single ventricle (SV) patients can be affected by stenosis or even closure. Aim of this study is to compare SV patients with and without PA-stent implantation post-BDCPC regarding risk factors for stent implantation and outcome. Single center, retrospective (2006-2021) study of 136 SV consecutive patients with and without PA-stent implantation post-BDCPC. Patient characteristics, risk factors for PA-stent implantation and PA growth were assessed comparing angiographic data pre-BDCPC and pre-TCPC. A total of 40/136 (29%) patients underwent PA-stent implantation at median (IQR) 14 (1.1-39.0) days post-BDCPC. 37/40 (92.5%) underwent LPA-stenting. Multiple regression analysis showed single LV patients to receive less likely PA-stents than single RV patients (OR 0.41; p = 0.05). Reduced LPA/BSA (mm/m2) and larger diameter of neo-ascending aorta pre-BDCPC were associated with an increased likelihood of PA-stent implantation post-BDCPC (OR 0.89, p = 0.03; OR 1.05, p = 0.001). Stent re-dilatation was performed in 36/40 (89%) after 1 (0.8-1.5) year. Pulmonary artery diameters pre-BDCPC were lower in the PA-stent group: McGoon (p < 0.001), Nakata (p < 0.001). Indexed pulmonary artery diameters increased equally in both groups but remained lower pre-TCPC in the PA-stent group: McGoon (p < 0.001), Nakata (p = 0.009), and Lower Lobe Index (p = 0.003). LPA and RPA grew symmetrically in both groups. Single RV, larger neo-ascending aorta, and small LPA pre- BDCPC are independent risk factors for PA-stent implantation post-BDCPC. Pulmonary artery diameters after PA-stent implantation and stent re-dilatation showed significant growth together with the contralateral side, but the PA-system remained symmetrically smaller in the stent group.

Persistent antegrade pulmonary blood flow post-glenn does not alter early post-Fontan outcomes in single-ventricle patients

BACKGROUND

The bidirectional Glenn cavopulmonary anastomosis (BDG) represents the standard interim procedure in treatment of patients with single-ventricle physiology. Anterograde pulmonary blood flow (APBF) maintained after BDG has been shown both to improve and to complicate postoperative clinical course. We studied its effects on outcome after BDG and eventual Fontan completion.

METHODS

From November 1995 to November 2005, 60 patients underwent BDG and Fontan. All patients had APBF from the ventricle to the pulmonary artery at time of BDG. In group 1 (n = 39) APBF was maintained after BDG, whereas APBF was interrupted at BDG in group 2 (n = 21). Cardiac catheterization data, interstage morbidity, and postoperative outcome variables were recorded.

RESULTS

Pre-BDG hemodynamics differed only in that the mean pulmonary artery pressure was higher in group 2 (17.0 +/- 4.4 mm Hg) than in group 1 (13.8 +/- 4.5 mm Hg; p = 0.03). There were no differences between groups 1 and 2 in BDG outcome variables. At pre-Fontan catheterization, group 1 had higher mean pulmonary artery pressure (13.3 versus 10.9 mm Hg, p = 0.01), arterial oxygen saturation (85.8 versus 80.9%, p = 0.0001), and fewer collateral vessels were coil embolized than in group 2 (0.9 versus 1.6, p = 0.02). Mean ventricular end-diastolic pressure was similar between groups. The Nakata index in group 1 remained stable from pre-BDG to pre-Fontan (348 versus 391, p = 0.24), but it decreased in group 2 (375 versus 227, p = 0.046).

CONCLUSIONS

Patients with anterograde pulmonary blood flow after BDG had a modest increase in pulmonary artery growth and arterial oxygen saturations, and decreased collateral vessel formation. This did not, however, confer additional benefit on outcome after BDG or on eventual Fontan completion.

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

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.

Coil occlusion of systemic venous collaterals in hypoplastic left heart syndrome

OBJECTIVE

To assess the frequency of systemic venous collaterals to the atria, which may cause desaturation, after stage II reconstructive surgery for hypoplastic left heart syndrome (HLHS) and to determine whether coil occlusion prevents the need for surgical ligation.

DESIGN

Prospective interventional study.

SETTING

Tertiary referral centre.

PATIENTS

27 children with HLHS undergoing cardiac catheterisation between October 1996 and February 2001.

INTERVENTIONS

19 children were catheterised prestage II, 1 poststage II, and 17 prestage III. Aortic oxygen saturation (SaAo) and pulmonary artery pressure (pPA) were recorded. Angiography was performed into the left internal jugular vein to look for venous collaterals. If present, they were occluded with Cook MReye coils. Angiography was repeated to confirm occlusion, and SaAo and pPA were remeasured.

RESULTS

Collaterals were found in 7 of 27 children: 1 poststage II and 6 prestage III. These were occluded with 1-3 coils without complication. Mean (SE) SaAo before occlusion was 80.2 (2.1)% in those with collaterals compared with 88.7 (1.0)% in those without (p = 0.007). There was no difference in mean pPA between the two groups. After coil occlusion mean SaAo rose to 83.8 (1.8)% (p = 0.007) and mean pPA rose from 12.5 (1.5) to 14.5 (1.8) mm Hg (p = 0.02). None required surgical ligation.

CONCLUSION

Angiography should be performed at catheterisation before stage II and III surgery for HLHS to exclude systemic venous collaterals. If present, they may be safely and effectively occluded with coils to improve saturation and prevent the need for subsequent surgical ligation.