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Beshish AG, Brady M, Golloshi K, Cote O, Gathoo A, Menon A, Qian J, Zinyandu T, Shaw FR, Maher KO, Deshpande SR. Impact of Antegrade Pulmonary Blood Flow as Patients Progress Through Single-Ventricle Palliations. Ann Thorac Surg 2024; 117:983-989. [PMID: 37527698 DOI: 10.1016/j.athoracsur.2023.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 06/01/2023] [Accepted: 07/11/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Asaad G Beshish
- Division of Pediatric Cardiology, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia.
| | | | | | - Olivia Cote
- Emory University School of Medicine, Atlanta, Georgia
| | - Asmita Gathoo
- Emory University School of Medicine, Atlanta, Georgia
| | - Ambika Menon
- Emory University School of Medicine, Atlanta, Georgia
| | - Joshua Qian
- Emory University School of Medicine, Atlanta, Georgia
| | | | - Fawwaz R Shaw
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Kevin O Maher
- Division of Pediatric Cardiology, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Shriprasad R Deshpande
- Division of Cardiology, Department of Pediatrics, Georgetown University School of Medicine, Children's National Hospital, Washington, DC
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Beshish AG, Amedi A, Harriott A, Patel S, Evans S, Scheel A, Xiang Y, Keesari R, Harding A, Davis J, Shashidharan S, Yarlagadda V, Aljiffry A. Short-Term Outcomes, Functional Status, and Risk Factors for Requiring Extracorporeal Life Support After Norwood Operation: A Single-Center Retrospective Study. ASAIO J 2024; 70:328-335. [PMID: 38557688 DOI: 10.1097/mat.0000000000002109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
Patients requiring extracorporeal life support (ECLS) post-Norwood operation constitute an extremely high-risk group. We retrospectively described short-term outcomes, functional status, and assessed risk factors for requiring ECLS post-Norwood operation between January 2010 and December 2020 in a high-volume center. During the study period, 269 patients underwent a Norwood procedure of which 65 (24%) required ECLS. Of the 65 patients, 27 (41.5%) survived to hospital discharge. Mean functional status scale (FSS) score at discharge increased from 6.0 on admission to 8.48 (p < 0.0001). This change was primary in feeding (p < 0.0001) and respiratory domains (p = 0.017). Seven survivors (26%) developed new morbidity, and two (7%) developed unfavorable functional outcomes. In the regression analysis, we showed that patients with moderate-severe univentricular dysfunction on pre-Norwood transthoracic echocardiogram (odds ratio [OR] = 6.97), modified Blalock Taussig Thomas (m-BTT) shunt as source of pulmonary blood flow (OR = 2.65), moderate-severe atrioventricular valve regurgitation on transesophageal echocardiogram (OR = 8.50), longer cardiopulmonary bypass time (OR = 1.16), longer circulatory arrest time (OR = 1.20), and delayed sternal closure (OR = 3.86), had higher odds of requiring ECLS (p < 0.05). Careful identification of these risk factors is imperative to improve the care of this high-risk cohort and improve overall outcomes.
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Affiliation(s)
- Asaad G Beshish
- Division of Cardiology, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Alan Amedi
- Emory University School of Medicine, Atlanta, Georgia
| | | | - Shayli Patel
- Emory University School of Medicine, Atlanta, Georgia
| | - Sean Evans
- Emory University School of Medicine, Atlanta, Georgia
| | - Amy Scheel
- Emory University School of Medicine, Atlanta, Georgia
| | - Yijin Xiang
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Rohali Keesari
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Amanda Harding
- Cardiac Sonographer, Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Joel Davis
- ECMO and Advanced Technologies, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Subhadra Shashidharan
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Vamsi Yarlagadda
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, California
| | - Alaa Aljiffry
- Division of Cardiology, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
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Davidson H, Zannino D, d’Udekem Y, Cordina R, Orr Y, Konstantinov IE, Weintraub R, Wheaton G, Saundankar J, Salve G, Iyengar A, Alphonso N, Ayer J. Does leaving native antegrade pulmonary blood flow at the time of the superior cavopulmonary connection impact long-term outcomes after the Fontan? JTCVS OPEN 2023; 16:825-835. [PMID: 38204641 PMCID: PMC10775047 DOI: 10.1016/j.xjon.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 08/08/2023] [Accepted: 09/05/2023] [Indexed: 01/12/2024]
Abstract
Objectives 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. Methods 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. Results 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). Conclusions 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.
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Affiliation(s)
- Hannah Davidson
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia
- Discipline of Paediatrics and Child Health, The University of Sydney, Sydney, Australia
| | - Diana Zannino
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia
| | - Yves d’Udekem
- Division of Cardiac Surgery, Children's National Hospital, Washington, DC
| | - Rachael Cordina
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
- Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Yishay Orr
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia
- Discipline of Paediatrics and Child Health, The University of Sydney, Sydney, Australia
| | - Igor E. Konstantinov
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Cardiac Surgery, Royal Children's Hospital Melbourne, Parkville, Australia
| | - Robert Weintraub
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, Faculty of Medicine, The University of Melbourne, Melbourne, Australia
- Department of Paediatric Cardiology, Royal Children's Hospital Melbourne, Parkville, Australia
| | - Gavin Wheaton
- Women's and Children's Hospital, Adelaide, Australia
| | - Jelena Saundankar
- Department of Paediatric Cardiology, Perth Children's Hospital, Perth, Australia
| | - Gananjay Salve
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia
| | - Ajay Iyengar
- Greenlane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand
| | - Nelson Alphonso
- Department of Cardiac Surgery, Queensland Children's Hospital, Brisbane, Australia
| | - Julian Ayer
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia
- Discipline of Paediatrics and Child Health, The University of Sydney, Sydney, Australia
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Dietzman TW, Soria S, DePaolo J, Gillespie MJ, Mascio C, Dori Y, O'Byrne ML, Rome JJ, Glatz AC. Influence of Antegrade Pulmonary Blood Flow on Outcomes of Superior Cavopulmonary Connection. Ann Thorac Surg 2022; 114:1771-1777. [PMID: 35341786 DOI: 10.1016/j.athoracsur.2022.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 03/02/2022] [Accepted: 03/08/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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). CONCLUSIONS 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.
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Affiliation(s)
- Thomas W Dietzman
- Division of Cardiac Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Stefania Soria
- Division of Cardiology, Department of Pediatrics, Rush University Medical Center, Chicago, Illinois
| | - John DePaolo
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Matthew J Gillespie
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christopher Mascio
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Yoav Dori
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michael L O'Byrne
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jonathan J Rome
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Andrew C Glatz
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Kalia K, Walker-Smith P, Ordoñez MV, Barlatay FG, Chen Q, Weaver H, Caputo M, Stoica S, Parry A, Tulloh RMR. Does Maintenance of Pulmonary Blood Flow Pulsatility at the Time of the Fontan Operation Improve Hemodynamic Outcome in Functionally Univentricular Hearts? Pediatr Cardiol 2021; 42:1180-1189. [PMID: 33876263 PMCID: PMC8192359 DOI: 10.1007/s00246-021-02599-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 04/01/2021] [Indexed: 11/08/2022]
Abstract
It is unclear whether residual anterograde pulmonary blood flow (APBF) at the time of Fontan is beneficial. Pulsatile pulmonary flow may be important in maintaining a compliant and healthy vascular circuit. We, therefore, wished to ascertain whether there was hemodynamic evidence that residual pulsatile flow at time of Fontan promotes clinical benefit. 106 consecutive children with Fontan completion (1999-2018) were included. Pulmonary artery pulsatility index (PI, (systolic pressure-diastolic pressure)/mean pressure)) was calculated from preoperative cardiac catheterization. Spectral analysis charted PI as a continuum against clinical outcome. The population was subsequently divided into three pulsatility subgroups to facilitate further comparison. Median PI prior to Fontan was 0.236 (range 0-1). 39 had APBF, in whom PI was significantly greater (median: 0.364 vs. 0.177, Mann-Whitney p < 0.0001). There were four early hospital deaths (3.77%), and PI in these patients ranged from 0.214 to 0.423. There was no correlation between PI and standard cardiac surgical outcomes or systemic oxygen saturation at discharge. Median follow-up time was 4.33 years (range 0.0273-19.6), with no late deaths. Increased pulsatility was associated with higher oxygen saturations in the long term, but there was no difference in reported exercise tolerance (Ross), ventricular function, or atrioventricular valve regurgitation at follow-up. PI in those with Fontan-associated complications or the requiring pulmonary vasodilators aligned with the overall population median. Maintenance of pulmonary flow pulsatility did not alter short-term outcomes or long-term prognosis following Fontan although it tended to increase postoperative oxygen saturations, which may be beneficial in later life.
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Affiliation(s)
- K Kalia
- Department of Congenital Heart Disease, University Hospitals Bristol and Weston NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8BJ, UK
| | - P Walker-Smith
- Department of Congenital Heart Disease, University Hospitals Bristol and Weston NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8BJ, UK
| | - M V Ordoñez
- Department of Congenital Heart Disease, University Hospitals Bristol and Weston NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8BJ, UK
| | - F G Barlatay
- Department of Congenital Heart Disease, University Hospitals Bristol and Weston NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8BJ, UK
| | - Q Chen
- Department of Congenital Heart Disease, University Hospitals Bristol and Weston NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8BJ, UK
| | - H Weaver
- Department of Congenital Heart Disease, University Hospitals Bristol and Weston NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8BJ, UK
| | - M Caputo
- Department of Congenital Heart Disease, University Hospitals Bristol and Weston NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8BJ, UK
| | - S Stoica
- Department of Congenital Heart Disease, University Hospitals Bristol and Weston NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8BJ, UK
| | - A Parry
- Department of Congenital Heart Disease, University Hospitals Bristol and Weston NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8BJ, UK
| | - R M R Tulloh
- Department of Congenital Heart Disease, University Hospitals Bristol and Weston NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8BJ, UK.
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Deshpande SR, Essa Y, Yerebakan C. Commentary: Flowers against nonflowers. J Thorac Cardiovasc Surg 2021; 162:1356-1357. [PMID: 33896604 DOI: 10.1016/j.jtcvs.2021.03.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 03/26/2021] [Accepted: 03/26/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Shriprasad R Deshpande
- Department of Cardiology, Children's National Heart Institute, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC; Department of Cardiovascular Surgery, Children's National Heart Institute, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC.
| | - Yasin Essa
- Department of Cardiology, Children's National Heart Institute, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Can Yerebakan
- Department of Cardiology, Children's National Heart Institute, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC; Department of Cardiovascular Surgery, Children's National Heart Institute, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
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Nagao H, Tanaka T. The Effect of Hypoxic Gas Therapy Using Nitrogen Before Bilateral Pulmonary Artery Banding on Hemodynamics and Pulmonary Artery Development. Pediatr Cardiol 2021; 42:637-642. [PMID: 33394113 DOI: 10.1007/s00246-020-02524-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 12/05/2020] [Indexed: 11/28/2022]
Abstract
This study aimed to identify its influence on pulmonary development and hemodynamics before bidirectional Glenn (BDG) anastomosis. This retrospective study involved 30 consecutive patients with univentricular hearts who underwent bilateral pulmonary artery banding (bil-PAB) and BDG anastomosis between September 2011 and September 2018 at our institution. These patients were classified into the nitrogen (N = 12) and no nitrogen (N = 18) groups according to their use of hypoxic gas therapy. Clinical echocardiographic, operative, and catheter examination data were reviewed. Nakata index was 131 (110-167) in the nitrogen group and 138 (88.4-161.7) in the no nitrogen group (P = 0.8). Pulmonary vascular resistance (PVR) was 1.50 (1.30-2.4) in the nitrogen group and 138 (88.4-161.7) in the no nitrogen group (P = 0.3). There was no statistical difference between the pulmonary development in both groups. In the subgroup of hypoplastic left heart syndrome patients, there was a statistical difference. RVEDV% of normal was 232.5 (215-239) in the nitrogen group and 201 (161-209) in the no nitrogen group (P = 0.03). Pulmonary development was not significantly different when hypoxic gas therapy was performed using nitrogen vs. not using nitrogen. However, RVEDV% of normal might be larger with hypoxic gas therapy using nitrogen. Although there is no obvious systemic atrioventricular valve regurgitation exacerbation with hypoxic gas therapy, it might be useful to prevent a decrease in PVR and may also affect bil-PAB and subclinical increase in systemic atrioventricular valve regurgitation.
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Affiliation(s)
- Hiroyuki Nagao
- Department of Cardiology, Hyogo Prefectural Kobe Children's Hospital, 1-6-7 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan.
| | - Toshikatsu Tanaka
- Department of Cardiology, Hyogo Prefectural Kobe Children's Hospital, 1-6-7 Minatojima-minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
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Ferns SJ, Zein CE, Subramanian S, Husayni T, Ilbawi MN. Post-Fontan pulmonary artery growth in patients with a bidirectional cavopulmonary shunt with additional antegrade pulsatile blood flow. Asian Cardiovasc Thorac Ann 2020; 29:743-750. [DOI: 10.1177/0218492320984095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Patients with antegrade pulmonary blood flow after a bidirectional cavopulmonary shunt (Glenn) may have better pulmonary artery growth. This study evaluated pulmonary artery growth in patients with and without prior additional pulsatile antegrade flow in a Glenn shunt at midterm follow-up after a Fontan procedure. Methods We reviewed 212 patients who had single-ventricle palliation in a 10-year period;103 (33 in pulsatile group 1 and 70 in nonpulsatile group 2) were selected for analysis. Data on demographics, procedures, perioperative course, and midterm follow-up after the Fontan procedure were compared. Echocardiography data were collected. Pulmonary artery sizes measured at cardiac catheterization and follow-up echocardiograms were used to calculate the Nakata index. Results Perioperative details were comparable in both groups, mean pulmonary artery pressure and systemic oxygen saturations were higher in group 1 compared to group 2. Venovenous collaterals were increased in group 1. There was a significant difference in the pre-Fontan and follow-up Nakata index between groups. There was a significant increase in the Nakata index in group 1 between the pre-Glenn and pre-Fontan assessments as well as the Nakata index between the pre-Fontan and midterm follow-up. There was no significant change in the Nakata index in group 2 between assessments. Conclusions A pulsatile Glenn shunt is associated with better pulmonary artery growth which continues long after the additional pulsatile flow is eliminated. It is possible that the effects of anterograde pulmonary blood flow on pulmonary artery growth in early life continue long after the Fontan completion.
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Affiliation(s)
- Sunita J Ferns
- University of Illinois at Chicago, Advocate Children’s Hospital, Oak Lawn, Illinois, USA
| | - Chawki El Zein
- University of Illinois at Chicago, Advocate Children’s Hospital, Oak Lawn, Illinois, USA
| | - Sujata Subramanian
- University of Illinois at Chicago, Advocate Children’s Hospital, Oak Lawn, Illinois, USA
| | - Tarek Husayni
- University of Illinois at Chicago, Advocate Children’s Hospital, Oak Lawn, Illinois, USA
| | - Michel N Ilbawi
- University of Illinois at Chicago, Advocate Children’s Hospital, Oak Lawn, Illinois, USA
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9
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Desai MH, Yerebakan C. Commentary: If only we knew when we would fail. J Thorac Cardiovasc Surg 2020; 161:1436-1437. [PMID: 33268127 DOI: 10.1016/j.jtcvs.2020.07.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 07/18/2020] [Accepted: 07/20/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Manan H Desai
- Department of Cardiovascular Surgery, Children's National Heart Institute, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC.
| | - Can Yerebakan
- Department of Cardiovascular Surgery, Children's National Heart Institute, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC
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10
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Chen X, Yuan H, Liu J, Zhang N, Zhou C, Huang M, Jian Q, Zhuang J. Hemodynamic Effects of Additional Pulmonary Blood Flow on Glenn and Fontan Circulation. Cardiovasc Eng Technol 2020; 11:268-282. [PMID: 32072439 DOI: 10.1007/s13239-020-00459-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 02/10/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE Additional pulmonary blood flow (APBF) can provide better pulsating blood flow and systemic arterial oxygen saturation, while low blood pulsation and low oxygen saturation are defects of the Fontan and Glenn procedure. Studying the hemodynamic effect of APBF is beneficial for clinical decisions. This study aimed to explore the effect on particle washout, as well as the differences among the sensitivities of both different hemodynamic parameters and different procedures to APBF. METHODS The patient-specific clinical datasets of a patient who underwent bilateral bidirectional Glenn (BBDG) with APBF were enrolled in this study, and using these datasets, Glenn- and Fontan-type artery models were reconstructed. A series of parameters, including the total caval flow pulsatility index (TCPI), indexed energy loss (iPL), wall shear stress (WSS), systemic arterial oxygen saturation (Satart), particle washout time (WOT), pressure in the right superior vena cava (PRSVC), pulmonary flow distribution (PFD) and hepatic flow distribution (HFD), were computed from computational fluid dynamic (CFD) simulation to evaluate the hemodynamic effect of APBF. RESULTS The result showed that APBF led to better iPL and Satart but worse PRSVC and heart load accompanied by a great impact on HFD, making hepatic flow easier to perfuse the side without MPA and APBF. The increase in the APBF rate also effectively results in larger flow pulsation, region velocity, and wall shear stress and lower WOT, and this effect may be more effective for patients with persistent left superior vena cava (PLSVC). However, APBF might have little effect on PFD. Furthermore, APBF might affect WOT, iPL and HFD more significantly than PRSVC and has a greater improvement effect in patients with poorer iPL and WOT. CONCLUSIONS Moderate APBF is not only a measure to promote pulmonary artery growth and systemic arterial oxygen saturation but also an effective method against endothelial dysfunction and thrombosis. However, moderate APBF is patient-specific and should be determined based on hemodynamic preference that leads to desired patient outcomes, and care should be taken to prevent PRSVC and heart load from being too high as well as an imbalance in HFD.
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Affiliation(s)
- Xiangyu Chen
- School of Mechanical and Automotive Engineering, South China University of Technology, Guangzhou, 510000, China
| | - Haiyun Yuan
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Department of Cardiovascular Surgery, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, 510000, China
| | - Jiawei Liu
- School of Mechanical and Automotive Engineering, South China University of Technology, Guangzhou, 510000, China
| | - Neichuan Zhang
- School of Mechanical and Automotive Engineering, South China University of Technology, Guangzhou, 510000, China
| | - Chengbin Zhou
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Department of Cardiovascular Surgery, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, 510000, China
| | - Meiping Huang
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Department of Catheterization Lab, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Qifei Jian
- School of Mechanical and Automotive Engineering, South China University of Technology, Guangzhou, 510000, China.
| | - Jian Zhuang
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Department of Cardiovascular Surgery, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, 510000, China.
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11
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Abstract
UNLABELLED BackgroundsThe aim of this study was to assess the impact of age at bidirectional cavopulmonary anastomosis on haemodynamics after total cavopulmonary connection. METHODS We conducted a retrospective analysis of 100 consecutive patients who underwent total cavopulmonary connection from 2010 to 2014. All patients had previously undergone bidirectional cavopulmonary anastomosis. These patients were classified into two groups according to age at bidirectional cavopulmonary anastomosis: younger group, 6 months (n=67). RESULTS The proportion of hypoplastic left heart syndrome was higher in the younger group (48 versus 4%). After total cavopulmonary connection, the chest tube period was longer in the younger group (10.1±6.6 versus 6.7±4.5 days; p=0.009). Catheterisation 6 months after total cavopulmonary connection revealed that pulmonary artery pressure was higher (11.5±1.9 versus 10.4±2.1 mmHg; p=0.017) and Nakata index was lower (219±79 versus 256±70 mm2/m2; p=0.024) in the younger group. In patients with a non-hypoplastic left heart syndrome, there was no difference in post-operative haemodynamics between two groups, but the total amount of chest drainage after total cavopulmonary connection was larger in the younger group (109±95 versus 55±40 ml/kg; p=0.044). CONCLUSIONS Early bidirectional cavopulmonary anastomosis did not affect the outcome of total cavopulmonary connection. Longer chest tube period, smaller pulmonary artery, and higher pulmonary artery pressure after total cavopulmonary connection were recognised in early bidirectional cavopulmonary anastomosis patients, especially in hypoplastic left heart syndrome.
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Yan T, Tong G, Zhang B, Yan F, Zhou X, Wang X, Lu H, Ma T, Wang X, Yu H, Sun Z, Zhang W. The effect of antegrade pulmonary blood flow following a late bidirectional Glenn procedure. Interact Cardiovasc Thorac Surg 2018; 26:454-459. [PMID: 29049710 DOI: 10.1093/icvts/ivx325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 09/01/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The effect of antegrade pulmonary blood flow (APBF) has never been studied in the bidirectional Glenn (BDG) procedure performed late. METHODS Records of 112 consecutive patients who had a BDG procedure during a 10-year period were reviewed retrospectively. The patients were divided into 2 groups based on whether APBF occurred following the BDG procedure (APBF group, n = 81) or not (non-APBF group, n = 31). The median age at the BDG procedure was 6.16 ± 3.93 years in the APBF group and 6.12 ± 4.40 years in the non-APBF group. RESULTS Demographics and pre- and intraoperative variables were comparable for both groups. Follow-up data were obtained for patients at the BDG stage and for those who had undergone the Fontan completion. Both oxygen saturation levels (81.72 ± 1.976% vs 78.32 ± 2.344%, P < 0.01) and pulmonary pressure (13.59 ± 1.376 mmHg vs 12.90 ± 0.978 mmHg, P = 0.012) were higher in the APBF group immediately after the BDG procedure. Both the duration of chest tube drainage and the total length of stay were longer in the APBF group. The pre-Glenn measurements showed a mean McGoon ratio of 1.68 ± 0.114 in the APBF group and 1.67 ± 0.098 in the non-APBF group (P = 0.474). The McGoon ratios measured before the Fontan procedure were also comparable (1.669 ± 0.726 vs 1.685 ± 0.669, P = 0.576). At the pre-Fontan measurement, there was no significant difference in mean pulmonary artery pressures between the groups (13.72 ± 1.368 vs 13.50 ± 1.265, P = 0.653). Fifty-nine patients underwent the Fontan completion (43 from the APBF group and 16 from the non-APBF group) procedure with a median of 1.2 (APBF group) and 1.4 (non-APBF group) years after the BDG procedure. No significant differences between groups were observed in arterial oxygen saturation levels, incidence of systemic atrioventricular valve regurgitation or ventricular dysfunction in survivors at the last follow-up visit. CONCLUSIONS The BDG procedure can be safely performed at a relatively older age (∼6 years). APBF increases oxygen saturation but also prolongs pleural effusion and hospital stay. Medium-term outcomes and the Fontan completion rate in the APBF and the non-APBF groups are comparable. Further large studies and long-term follow-up are needed to clarify the effect of APBF in patients who have the late BDG.
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Affiliation(s)
- Tao Yan
- Department of Cardiovascular Surgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, Guangdong Province, China
| | - Guang Tong
- Department of Cardiovascular Surgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, Guangdong Province, China
| | - Ben Zhang
- Department of Cardiovascular Surgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, Guangdong Province, China
| | - Feng Yan
- Department of Cardiothoracic Surgery, Zhangjiajie People's Hospital, Zhangjiajie, Hunan Province, China
| | - Xuan Zhou
- Department of Cardiology, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, Guangdong Province, China
| | - Xianyue Wang
- Department of Cardiovascular Surgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, Guangdong Province, China
| | - Hua Lu
- Department of Cardiovascular Surgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, Guangdong Province, China
| | - Tao Ma
- Department of Cardiovascular Surgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, Guangdong Province, China
| | - Xiaowu Wang
- Department of Cardiovascular Surgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, Guangdong Province, China
| | - Hao Yu
- Department of Cardiovascular Surgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, Guangdong Province, China
| | - Zhongchan Sun
- Department of Cardiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Weida Zhang
- Department of Cardiovascular Surgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, Guangdong Province, China
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Talwar S, Kumar MV, Sreenivas V, Gupta VP, Choudhary SK, Airan B. Exercise performance after univentricular palliation. Ann Pediatr Cardiol 2018; 11:40-47. [PMID: 29440829 PMCID: PMC5803976 DOI: 10.4103/apc.apc_43_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: The optimal timing, need for primary/staged procedure in patients undergoing univentricular palliation, is debatable. Aims: We performed this study to assess the exercise performance of patients undergoing various forms of univentricular palliation. Setting and Design: This was a retrospective, prospective comparative study conducted at a multispecialty tertiary referral center. Patients and Methods: Between January 2012 and June 2015, 117 patients undergoing either bidirectional Glenn (BDG) (n = 43) or Fontan (total cavopulmonary connection [TCPC]) (n = 74) underwent exercise testing. Statistical Analysis: Comparisons between subgroups for continuous data were made with Student's t-test if normally distributed and Wilcoxon rank-sum test otherwise. Tests between subgroups for qualitative data were made with Pearson's Chi-square test. Results: Patients who underwent BDG with open antegrade pulmonary blood flow (APBF) had higher saturations (oxygen saturation [SpO2]) compared to those without it (87.5 ± 5.0% vs. 81.1 ± 4.8%; P = 0.0001). However, we found no differences in exercise parameters of patients undergoing BDG with or without APBF. Extracardiac TCPC (n = 42) patients demonstrated better exercise capacity (15.0 ± 7.7 vs. 11.2 ± 6.2 min; P = 0.02) and increased SpO2 on exercise (87.0 ± 8.0% vs. 83.4 ± 7.6%; P ≤ 0.05) compared to lateral tunnel TCPC (n = 32). Fenestrated TCPC (n = 30) patients had higher exercise capacity reflected by higher metabolic equivalents (METs) consumption (6.4 ± 2.3 vs. 5.2 ± 2.0 METs, P = 0.02), fewer pleural effusions (7.0 ± 3.2 vs. 9.2 ± 6.2 days, P ≤ 0.05), and lower hospital stay (9.5 ± 4.0 vs. 12.7 ± 7.7 days, P = 0.04) compared to nonfenestrated TCPC (n = 44) patients. Conclusions: We observed no differences in exercise parameters of patients undergoing BDG with or without APBF. Extracardiac TCPC patients had better exercise capacity but longer postoperative hospital stay and pleural effusions than patients with lateral tunnel Fontan. Fenestrated TCPC patients seemed to fare better than nonfenestrated ones. Patients undergoing TCPC had better exercise capacity than patients undergoing BDG alone.
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Affiliation(s)
- Sachin Talwar
- Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Manikala Vinod Kumar
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | | | - Vishwa Prakash Gupta
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | | | - Balram Airan
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
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Casella SL, Kaza A, del Nido P, Lock JE, Marshall AC. Targeted Increase in Pulmonary Blood Flow in a Bidirectional Glenn Circulation. Semin Thorac Cardiovasc Surg 2018; 30:182-188. [DOI: 10.1053/j.semtcvs.2018.02.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2018] [Indexed: 11/11/2022]
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Aortic valve perforation following Amplatzer vascular plug device closure of ‘pulsatile’ Fontan. PROGRESS IN PEDIATRIC CARDIOLOGY 2017. [DOI: 10.1016/j.ppedcard.2017.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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16
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Nichay NR, Gorbatykh YN, Kornilov IA, Soynov IA, Kulyabin YY, Gorbatykh AV, Ivantsov SM, Bogachev-Prokophiev AV, Karaskov AM. Risk Factors For Unfavorable Outcomes After Bidirectional Cavopulmonary Anastomosis. World J Pediatr Congenit Heart Surg 2017; 8:575-583. [DOI: 10.1177/2150135117728505] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background: Bidirectional cavopulmonary anastomosis (BCPA) is an important preliminary step toward the Fontan procedure; thus, understanding of risk factors for morbidity and mortality after BCPA may ultimately promote improved rates of success with Fontan completion and general survival. This study evaluated survival and predictors of unfavorable outcomes in patients after BCPA. Methods: Clinical data of 157 patients who underwent BCPA from 2003 to 2015 at a single center were retrospectively analyzed. Results: Three-year and nine-year survival after BCPA were 87.1% ± 2.8% and 85.8% ± 2.9%, respectively. Freedom from unfavorable outcomes (mortality, BCPA takedown, nonsuitability for Fontan procedure) was 83.8% ± 3.1% at three years and 73.5% ± 4.8% at nine years. Multivariate proportional hazards regression analysis revealed that total anomalous pulmonary venous connection (TAPVC; hazard ratio [HR]: 3.74, 95% confidence interval [CI]: 1.35-10.36; P = .01) and increased mean pressure in BCPA circuit (HR: 1.17, 95% CI: 1.02-1.34; P = .03) were independent risk factors for unfavorable outcomes. Postoperative mean pressure in BCPA circuit in patients with poor outcomes was median 16 mm Hg (interquartile range [IQR]: 14-18 mm Hg) versus median 14 mm Hg (IQR: 12-15.5 mm Hg) in patients with favorable outcomes ( P < .01). Preoperative (HR: 1.87, 95% CI: 1.20-2.91; P < .01) and postoperative atrioventricular valve regurgitation (AVVR; HR: 2.22, 95% CI: 1.24-3.94; P < .01) were also associated with unfavorable outcome in univariate Cox regression. Conclusions: Elevated mean pressure in the BCPA circuit is the main predictor of unfavorable outcome; therefore, thorough preoperative examination and careful patient selection are critical points for successful intermediate-stage and later Fontan completion. Total anomalous pulmonary venous connection and insufficient correction of AVVR worsen the prognosis in this patient group.
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Affiliation(s)
- Nataliya R. Nichay
- Department of Congenital Heart Disease, Siberian Biomedical Research Center, Ministry of Health Russian Federation, Novosibirsk, Russian Federation
| | - Yuriy N. Gorbatykh
- Department of Congenital Heart Disease, Siberian Biomedical Research Center, Ministry of Health Russian Federation, Novosibirsk, Russian Federation
| | - Igor A. Kornilov
- Department of Anesthesiology, Siberian Biomedical Research Center, Ministry of Health Russian Federation, Novosibirsk, Russian Federation
| | - Ilya A. Soynov
- Department of Congenital Heart Disease, Siberian Biomedical Research Center, Ministry of Health Russian Federation, Novosibirsk, Russian Federation
| | - Yuriy Y. Kulyabin
- Department of Congenital Heart Disease, Siberian Biomedical Research Center, Ministry of Health Russian Federation, Novosibirsk, Russian Federation
| | - Artem V. Gorbatykh
- Department of Congenital Heart Disease, Siberian Biomedical Research Center, Ministry of Health Russian Federation, Novosibirsk, Russian Federation
| | - Sergey M. Ivantsov
- Department of Congenital Heart Disease, Siberian Biomedical Research Center, Ministry of Health Russian Federation, Novosibirsk, Russian Federation
| | - Alexander V. Bogachev-Prokophiev
- Department of Congenital Heart Disease, Siberian Biomedical Research Center, Ministry of Health Russian Federation, Novosibirsk, Russian Federation
| | - Alexander M. Karaskov
- Department of Congenital Heart Disease, Siberian Biomedical Research Center, Ministry of Health Russian Federation, Novosibirsk, Russian Federation
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Metras A, Fouilloux V, Al-Yamani M, Roques X, Macé L, Thambo JB, Metras D, Kreitmann B, Roubertie F. Early to mid-term results after total cavopulmonary connection performed in the second decade of life. Interact Cardiovasc Thorac Surg 2017; 24:762-767. [PMID: 28453799 DOI: 10.1093/icvts/ivw427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 11/23/2016] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Total cavopulmonary connection (TCPC) performed in the second decade of life has rarely been studied. Thus, we investigated (bicentric study) early and late morbidity and mortality following completion of TCPC in these patients. METHODS From January 1999 to June 2014, 63 patients (14.5 ± 2.9 years) underwent TCPC (extracardiac conduit). Palliation before completion was an isolated bidirectional cavopulmonary shunt (BCPS) in 3 patients or BCPS associated with additional pulmonary blood flow (APBF) that was either antegrade (Group 1) in 38 (63%) or retrograde (Group 2) in 22 (37%). Preoperative and perioperative data were reviewed retrospectively. RESULTS Mean pulmonary arterial and ventricular end-diastolic pressures were 12.2 and 9.2 mmHg, respectively. Mean Nakata index was 279 ± 123 and 228 ± 87 mm 2 /m 2 in Groups 1 and 2, respectively ( P = 0.01). Aortic cross-clamping was performed in 22 from Group 1 and 8 from Group 2 ( P = 0.04). Mean follow-up was 4.57 years [0.8-15]. Nine patients had prolonged stays in the intensive care unit (>6 days). There were 1 early and 2 late deaths (non-cardiac related). Actuarial survival was 96% at 4 years. At last follow-up, single-ventricle function remained normal or improved in all patients (Group 1) compared to 82% in Group 2 ( P = 0.02). New York Heart Association (NYHA) class had improved in both groups: 47 patients were NYHA class II and 16 class III preoperatively vs 50 class I and 10 class II postoperatively ( P < 0.001). CONCLUSIONS Single-ventricle palliation with BCPS and APBF allowed completion of TCPC in the second decade of life, with encouraging mid-term results. However, BCPS with retrograde APBF was associated with single-ventricle dysfunction: thus, this technique needs to be used cautiously as long-lasting palliation.
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Affiliation(s)
- Alexandre Metras
- Department of Cardiovascular Surgery, Bordeaux Heart University Hospital, University of Bordeaux II, France
| | - Virginie Fouilloux
- Department of Cardiothoracic Surgery, Children's Hospital La Timone, Marseille, France
| | - Mohammed Al-Yamani
- Department of Cardiovascular Surgery, Bordeaux Heart University Hospital, University of Bordeaux II, France
| | - Xavier Roques
- Department of Cardiovascular Surgery, Bordeaux Heart University Hospital, University of Bordeaux II, France
| | - Loic Macé
- Department of Pediatric Cardiology, Bordeaux Heart University Hospital, University of Bordeaux II, France
| | - Jean-Benoît Thambo
- Department of Pediatric Cardiology, Bordeaux Heart University Hospital, University of Bordeaux II, France
| | - Dominique Metras
- Department of Cardiothoracic Surgery, Children's Hospital La Timone, Marseille, France
| | - Bernard Kreitmann
- Department of Cardiovascular Surgery, Bordeaux Heart University Hospital, University of Bordeaux II, France
| | - François Roubertie
- Department of Cardiovascular Surgery, Bordeaux Heart University Hospital, University of Bordeaux II, France
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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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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. Cardiol Young 2016; 26:288-97. [PMID: 25704070 DOI: 10.1017/s1047951115000153] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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.
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Surgical management of competing pulmonary blood flow affects survival before Fontan/Kreutzer completion in patients with tricuspid atresia type I. J Thorac Cardiovasc Surg 2015; 150:1222-30.e7. [DOI: 10.1016/j.jtcvs.2015.05.067] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 05/11/2015] [Accepted: 05/24/2015] [Indexed: 12/28/2022]
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Sughimoto K, Zannino D, Mathew J, Weintraub RG, Brizard CP, d’Udekem Y, Konstantinov IE. Forward Flow Through the Pulmonary Valve After Bidirectional Cavopulmonary Shunt Benefits Patients at Fontan Operation. Ann Thorac Surg 2015; 100:1390-6; discussion 1396-7. [DOI: 10.1016/j.athoracsur.2015.05.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 05/01/2015] [Accepted: 05/05/2015] [Indexed: 11/28/2022]
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Evans WN, Acherman RJ, Winn BJ, Yumiaco NS, Galindo A, Rothman A, Restrepo H. Fontan hepatic fibrosis and pulmonary vascular development. Pediatr Cardiol 2015; 36:657-61. [PMID: 25381625 DOI: 10.1007/s00246-014-1061-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 10/31/2014] [Indexed: 11/25/2022]
Abstract
Fontan patients are at risk for hepatic fibrosis; however, risk factors are unclear. We performed a multivariate analysis in a small cohort of 14 patients (7-24 years old, mean 15) with Fontan circulation, undergoing cardiac catheterization and transvenous liver biopsies, all demonstrating fibrosis. We found by stepwise regression analysis that the history of pulmonary atresia was a predictor of higher total hepatic fibrosis scores than a history of unobstructed pulmonary blood flow (p = 0.002). Other variables including age, time from Fontan, hemodynamic measurements, and laboratory values were not predictive of total fibrosis scores at p values <0.05. Hepatic fibrosis scores between those born with pulmonary atresia versus unrestricted pulmonary blood flow may reflect differences in pulmonary circulatory physiology, resulting from differences in pulmonary vascular development.
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Affiliation(s)
- William N Evans
- Children's Heart Center - Nevada, 3006 S. Maryland Pkwy Ste. 690, Las Vegas, NV, 89109, USA,
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Davies RR, Pizarro C. Decision-Making for Surgery in the Management of Patients with Univentricular Heart. Front Pediatr 2015; 3:61. [PMID: 26284226 PMCID: PMC4515559 DOI: 10.3389/fped.2015.00061] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 06/21/2015] [Indexed: 12/24/2022] Open
Abstract
A series of technical refinements over the past 30 years, in combination with advances in perioperative management, have resulted in dramatic improvements in the survival of patients with univentricular heart. While the goal of single-ventricle palliation remains unchanged - normalization of the pressure and volume loads on the systemic ventricle, the strategies to achieve that goal have become more diverse. Optimal palliation relies on a thorough understanding of the changing physiology over the first years of life and the risks and consequences of each palliative strategy. This review describes how to optimize surgical decision-making in univentricular patients based on a current understanding of anatomy, physiology, and surgical palliation.
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Affiliation(s)
- Ryan Robert Davies
- Nemours Cardiac Center, A. I. duPont Hospital for Children , Wilmington, DE , USA ; Thomas Jefferson University , Philadelphia, PA , USA
| | - Christian Pizarro
- Nemours Cardiac Center, A. I. duPont Hospital for Children , Wilmington, DE , USA ; Thomas Jefferson University , Philadelphia, PA , USA
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