Textbook Outcome for Superior Cavopulmonary Connection: A Metric for Single Ventricle Heart Surgery

Background: To develop a more holistic measure of congenital heart center performance beyond mortality, we created a composite "textbook outcome" (TO) for the Glenn operation. We hypothesized that meeting TO would have a positive prognostic and financial impact. Methods: This was a single center retrospective study of patients undergoing superior cavopulmonary connection (bidirectional Glenn or Kawashima ± concomitant procedures) from 2005 to 2021. Textbook outcome was defined as freedom from operative mortality, reintervention, 30-day readmission, extracorporeal membrane oxygenation, major thrombotic complication, length of stay (LOS) >75th percentile (17d), and mechanical ventilation duration >75th percentile (2d). Multivariable logistic regression and Cox proportional hazards modeling were used. Results: Fifty-one percent (137/269) of patients met TO. Common reasons for TO failure were prolonged LOS (78/132, 59%) and ventilator duration (67/132, 51%). In multivariable analysis, higher weight [odds ratio, OR: 1.44 (95% confidence interval, CI: 1.15-1.84), P = .002] was a positive predictor of TO achievement while right ventricular dominance [OR 0.47 (0.27-0.81), P = .007] and higher preoperative pulmonary vascular resistance [OR 0.58 (0.40-0.82), P = .003] were negative predictors. After controlling for preoperative factors and excluding operative mortalities, TO achievement was independently associated with a decreased risk of death over long-term follow-up [hazard ratio: 0.50 (0.25-0.99), P = .049]. Textbook outcome achievement was also associated with lower direct cost of care [$137,626 (59,333-167,523) vs $262,299 (114,200-358,844), P < .0001]. Conclusion: Achievement of the Glenn TO is associated with long-term survival and lower costs and can be predicted by certain risk factors. As outcomes continue to improve within congenital heart surgery, operative mortality will become a less informative metric. Textbook outcome analysis may represent a more balanced measure of a successful outcome.

Attrition between the superior cavopulmonary connection and the Fontan procedure in hypoplastic left heart syndrome

OBJECTIVE

We investigated the incidence and predictors of failure to undergo the Fontan in children with hypoplastic left heart syndrome who survived superior cavopulmonary connection.

METHODS

The cohort consists of all patients with hypoplastic left heart syndrome who survived to hospital discharge after superior cavopulmonary connection between 1988 and 2017. The primary outcome was attrition, which was defined as death, nonsuitability for the Fontan, or cardiac transplantation before the Fontan. Subjects were excluded if they were awaiting the Fontan, were lost to follow-up, or underwent biventricular repair. The study period was divided into 4 eras based on changes in operative or medical management. Attrition was estimated with 95% confidence intervals, and predictors were identified using adjusted, logistic regression models.

RESULTS

Of the 856 hospital survivors after superior cavopulmonary connection, 52 died, 7 were deemed unsuitable for Fontan, and 12 underwent or were awaiting heart transplant. Overall attrition was 8.3% (71/856). Attrition rate did not change significantly across eras. A best-fitting multiple logistic regression model was used, adjusting for superior cavopulmonary connection year and other influential covariates: right ventricle to pulmonary artery shunt at Norwood (P < .01), total support time at superior cavopulmonary connection (P < .01), atrioventricular valve reconstruction at superior cavopulmonary connection (P = .02), performance of other procedures at superior cavopulmonary connection (P = .01), and length of stay after superior cavopulmonary connection (P < .01).

CONCLUSIONS

In this study spanning more than 3 decades, 8.3% of children with hypoplastic left heart syndrome failed to undergo the Fontan after superior cavopulmonary connection. This attrition rate has not decreased over 30 years. Use of a right ventricle to pulmonary artery shunt at the Norwood procedure was associated with increased attrition.

Contemporary survival of patients with pulmonary arterial hypertension and congenital systemic to pulmonary shunts

OBJECTIVE

To compare survival of patients with newly diagnosed pulmonary arterial hypertension associated with congenital heart disease (PAH-CHD) according to various clinical classifications with classifications of anatomical-pathophysiological systemic to pulmonary shunts in a single-center cohort.

METHODS

All prevalent cases of PAH-CHD with hemodynamic confirmation by cardiac catheterization in 1995-2015 were retrospectively reviewed. Patients who were younger than three months of age, or with single ventricle following surgery were excluded. Baseline characteristics and clinical outcomes were retrieved from the database. The survival analysis was performed at the end of 2016. Prognostic factors were identified using multivariate analysis.

RESULTS

A total of 366 consecutive patients (24.5 ± 17.6 years of age, 40% male) with PAH-CHD were analyzed. Most had simple shunts (85 pre-tricuspid, 105 post-tricuspid, 102 combined shunts). Patients with pre-tricuspid shunts were significantly older at diagnosis in comparison to post-tricuspid, combined, and complex shunts. Clinical classifications identified patients as having Eisenmenger syndrome (ES, 26.8%), prevalent left to right shunt (66.7%), PAH with small defect (3%), or PAH following defect correction (3.5%). At follow-up (median = 5.9 years; 0.1-20.7 years), no statistically significant differences in survival rate were seen among the anatomical-pathophysiological shunts (p = 0.1). Conversely, the clinical classifications revealed that patients with PAH-small defect had inferior survival compared to patients with ES, PAH post-corrective surgery, or PAH with prevalent left to right shunt (p = 0.01). Significant mortality risks were functional class III, age < 10 years, PAH-small defect, elevated right atrial pressure > 15 mmHg, and baseline PVR > 8 WU•m.2.

CONCLUSION

Patients with PAH-CHD had a modest long-term survival. Different anatomical-pathophysiological shunts affect the natural presentation, while clinical classifications indicate treatment strategies and survival. Contemporary therapy improves survival in deliberately selected patients.

Cavopulmonary anastomosis without cardiopulmonary bypass

OBJECTIVES

There is an increasing trend to perform the bidirectional superior cavopulmonary (Glenn) anastomosis without cardiopulmonary bypass. In this report, we present our results of off-pump bidirectional Glenn operation done without using a venoatrial shunt to decompress the superior vena cava during clamping. [corrected].

METHODS

A prospective, non-randomized comparative study was conducted in 50 patients with functional single ventricle anomalies who underwent bidirectional Glenn anastomosis without cardiopulmonary bypass. The patients were divided into two groups: Group I (n = 25), where it was done without a veno-atrial shunt, and Group II (n = 25), where it was done with a veno-atrial shunt. Two patients in Group I and 4 patients in Group II had a bilateral bidirectional Glenn shunt. Five patients in Group I and three patients in Group II had a previous left modified Blalock-Taussig shunt. All patients underwent a complete neurological examination both preoperatively as well as postoperatively.

RESULTS

The early hospital mortality was 4% (2/50), one in each group. The median follow-up was 14 months. The mean internal venous pressure on clamping the superior vena cava was 37.07 ± 7.12 mmHg in Group I and 24 ± 4.4 mmHg in Group II. The mean clamp time was 9.85 ± 3.52 min in Group I and 21.3 ± 4.4 min in Group II. The transcranial pressure gradient was 62.37 ± 15.01 mmHg in Group I, while 65.08 ± 13.89 in Group II. The mean intensive care unit stay was 2.57 ± 75 days in Group I, 3.3 ± 1.09 in Group II. There were no major neurological complications apart from treatable convulsions in one case in Group I (4%), 2 cases in Group II (8%), and delayed recovery in one case (4%) in Group I.

CONCLUSIONS

Off-pump bidirectional Glenn operation without caval decompression is a safe, simple and more economic procedure.

Survival after bidirectional cavopulmonary anastomosis: Analysis of preoperative risk factors

OBJECTIVE

Prognostic factors for survival after bidirectional cavopulmonary anastomosis for functionally single ventricle are not well defined. We analyzed preoperative hemodynamic and echocardiographic data to determine risk factors for death or transplantation at least 1 year after bidirectional cavopulmonary anastomosis.

METHODS

Data for all patients who underwent bidirectional cavopulmonary anastomosis before 5 years of age at our institution from September 1995 through June 2005 were analyzed. Available preoperative echocardiograms and catheterizations were reviewed. Survivors were compared with those who died or underwent transplantation. Bivariable associations between demographic and clinical risk factors and survival status (alive without transplantation vs dead or transplanted) were assessed with Wilcoxon rank sum test and chi2 or Fisher exact tests. Survival functions were constructed with Kaplan-Meier estimates, and event times compared between subgroups with log-rank tests. Cox proportional hazard modeling was used for multivariable modeling of risk of death or transplantation.

RESULTS

One hundred sixty-seven patients underwent bidirectional cavopulmonary anastomosis with hemi-Fontan (n = 62) or bidirectional Glenn (n = 105) operations. Three patients died before discharge, 11 died later, and 1 has undergone transplantation. Freedom from death or transplantation after bidirectional cavopulmonary anastomosis was 96% at 1 year and 89% at 5 years. Multivariable analysis of preoperative variables showed atrioventricular valve regurgitation to be an independent risk factor for death or transplantation (hazard ratio 2.8, 95% confidence interval 1.1-7.1, P = .02).

CONCLUSION

Although survival after bidirectional cavopulmonary anastomosis is high, preoperative atrioventricular valve regurgitation is an important risk factor for death or transplantation.

Interim Mortality in Pulmonary Atresia With Intact Ventricular Septum

BACKGROUND

Recent work has focused attention on interim mortality (death after hospital discharge and before second-stage surgery) in hypoplastic left heart syndrome. This study investigates interim mortality in infants undergoing systemic-to-pulmonary artery shunts for pulmonary atresia with intact ventricular septum.

METHODS

At two centers in 11 years (January 1991 through December 2001), 35 infants underwent placement of shunts for palliation of pulmonary atresia with intact septum. Patients were identified from the cardiology database at each institution, and data were collected retrospectively. The infants were classified into two groups, with and without severe right ventricular hypoplasia, based on the initial surgical plan (Fontan or two-ventricle repair).

RESULTS

The mean age and weight of the infants were 9 days and 3.1 kg. The right ventricle was severely hypoplastic in 22 of 35 infants. Hospital death occurred in 2 patients (9.1%), 1 with severe right ventricular hypoplasia. The remaining 33 patients form the study population. There were a total of 5 deaths (15%) after discharge and before second-stage operation, all in patients with severe right ventricular hypoplasia. Two patients, 1 with hypoplastic right ventricle, died after second-stage operation.

CONCLUSIONS

These data confirm a significant incidence of interim death in infants with pulmonary atresia and hypoplastic right ventricle. The interim mortality rate in the current two-institution study of infants with pulmonary atresia with intact ventricular septum is similar to that in hypoplastic left heart syndrome if all patients are considered (15%), and is somewhat higher (24%) than that for hypoplastic left heart syndrome if only patients with severe right ventricular hypoplasia are considered. This rate of interim death must be considered when different treatment options (such as shunt or transplant) are contemplated.

Early cavopulmonary anastomosis in very young infants after the Norwood procedure: impact on oxygenation, resource utilization, and mortality

BACKGROUND

The optimal timing of second-stage palliation after Norwood operations remains undefined. Advantages of early cavopulmonary anastomosis are early elimination of volume load and shortening the high-risk interstage period. Potential disadvantages include severe cyanosis, prolonged pleural drainage and hospitalization, and excess mortality. We reviewed our recent experience to evaluate the safety of early cavopulmonary anastomosis.

METHODS

Eighty-five consecutive patients undergoing post-Norwood operation cavopulmonary anastomosis were divided into group I (cavopulmonary anastomosis at <4 months; n = 33) and group II (cavopulmonary anastomosis at >4 months; n = 52). Groups were compared for age; size; early and late mortality; preoperative, initial postoperative, and discharge oxygen saturation; and duration of mechanical ventilation, intensive care unit stay, pleural drainage, and hospitalization.

RESULTS

Group I patients were younger than group II patients (94 +/- 21 days vs 165 +/- 44 days, respectively; P <.001) and smaller (4.8 +/- 0.8 kg vs 5.8 +/- 0.9 kg; P <.001). The preoperative oxygen saturation was not different (group I, 75% +/- 10%; group II, 78% +/- 8%; P =.142). The oxygen saturation was lower immediately after surgery in group I compared with group II (75% +/- 7% vs 81% +/- 7%, respectively; P <.001) but not by discharge (group I, 79% +/- 4%; group II, 80% +/- 4%). Younger patients were ventilated longer (62 +/- 86 hours vs 19 +/- 42 hours; P =.001), in the intensive care unit longer (130 +/- 111 hours vs 104 +/- 94 hours; P =.049), hospitalized longer (12.5 +/- 11.5 days vs 10.3 +/- 14.8 days; P =.012), and required longer pleural drainage (106 +/- 45 hours vs 104 +/- 93 hours; P =.046). Hospital survival was 100% in both groups. Actuarial survival to 12 months was 96% +/- 4% for group I and 96% +/- 3% for group II.

CONCLUSIONS

Early cavopulmonary anastomosis after the Norwood operation is safe. Younger patients are more cyanotic initially after surgery and have a longer duration of mechanical ventilation, pleural drainage, intensive care unit stay, and hospitalization.

[Long-term results after the total cavopulmonary connection]

Between July, 1988 and November, 2002, 108 patients underwent total cavopulmonary connection (TCPC) at Kobe Children's Hospital. The primary malformation was univentricular heart in 40 tricuspid atresia in 21, mitral atresia in 16, and other complex cardiac defects in the remaining 31. Fenestrated TCPC, staged TCPC, and off-pump TCPC were performed in 39, 26, and 15 high risk patients, respectively. Nitric oxide inhalation was administered in 46 patients. The mean follow-up period was 4.3 years (range, 1 month to 14 years). There were 10 early deaths due to low cardiac output syndrome in 4, thrombosis in 3, tracheal bleeding in 2, and disseminated intravascular coagulation in 1. There were 5 late deaths due to congestive heart failure in 2 patients, arrhythmia in 1, cerebral infarction in 1, and subarachnoid hemorrhage in 1. Late complications included arrhythmia in 17 patients, systemic desaturation caused by abnormal systemic venous channels in 10, pleural or pericardial effusion in 3, chylothorax in 1, and aortic valve incompetence in 1.

[Long-term surgical results of total cavopulmonary connection in children with visceral heterotaxy syndrome; comparison between lateral tunnel method and extracardiac conduit method]

We reviewed our 58 experience of total cavopulmonary connection (TCPC) for children with visceral heterotaxy syndrome from 1992 to 1999. Surgical results, pre- and post-operative hemodynamics, and the incidence of cardiac-related events were compared between lateral tunnel method (LT) and extra-cardiac conduit method (EC). Overall survival rate was 89.6% in 8 years. Freedom from cardiac-related events was significantly lower in LT method compared with EC method (70.8% vs. 91.3% in 5 years and 67.8% vs. 91.3% in 8 years, p = 0.048). Extra-cardiac conduit TCPC following bi-directional Glenn shunt is the procedure of choice for children with visceral heterotaxy syndrome and functional single ventricle.

[Fontan procedure: early and mid-term results with total cavopulmonary anastomosis]

BACKGROUND

During the last five years, 65 patients with univentricular heart have been treated surgically in our institution, according to a protocol of staged operations that have been previously reported.

AIM

To evaluate the early and mid-term outcome of those patients that have completed their staging protocol by means of a Fontan procedure.

PATIENTS AND METHODS

Between April 1996 and June 2001, 23 patients (age 16 to 223 months) underwent a Fontan procedure, 15 with an intracardiac lateral tunnel technique and 8 with an extracardiac conduit. A retrospective review of their clinical, surgical, echocardiographic, angiographic and hemodynamic data was performed, trying to identify risk factors for both mortality and functional capacity (FC). Follow up was complete in all survivors.

RESULTS

Three patients died early after surgery (13.04%). Excessive pulmonary blood flow was a risk factor for early death (p = 0.03). One patient died at 14 months. Follow up was 29.9 months (1-63). For those who survived the operation, five years survival was 93.3%. The majority of patients are in FC I or II, with no related risk factors.

CONCLUSIONS

Our current results are comparable with those of larger series. Patients reach good FC and mid-term survival, irrespective of type of single ventricle or the surgical strategy.

Fontan operation and the cavopulmonary technique: immediate and late results according to the presence of atrial fenestration

OBJECTIVE

To compare immediate and late results in patients with or without fenestration who underwent cavopulmonary anastomosis so that we could assess the efficiency of the technique.

METHODS

Sixty-two patients underwent surgery between 1988 and 1999, 41 with fenestration (group I -G I) and 21 without fenestration (group II -G II). Tricuspid atresia was prevalent in group I (23-56%) and single ventricle was prevalent in group II (14-66%). Mean ages at the time of operation were 7.3 years in group I and 7.6 in group II. At late follow-up, mean ages were 10.6 years in group I and 12.8 years in group II.

RESULTS

Immediate and late mortality were 7.3% in G-I and 4.7% in G-II. Significant pleural effusion occurred in 41.4% of G-I patients and in 23.8% of G-II patients. Significant pericardial effusion occurred in 29.2% and 14.2%, respectively, in groups I and II. Central venous pressure was greater in G-II, 17.7 cm in H2O, as opposed to 15 cm in G-I. Hospital stay was similar between the groups, 26.3 and 21.8 days, respectively. Cyanosis and arterial insaturation occurred in 5 patients, and 4 patients were in functional class II, all from G-I. At late follow-up, 58 (93.5%) were in functional class I. Sinus rhythm was present in 94%, and pulmonary perfusion was similar in both groups. Eleven patients who underwent spirometry had good tolerance to physical effort.

CONCLUSION

Atrial fenestration did not improve the immediate or late follow-up of patients who underwent cavopulmonary anastomosis, and is, therefore, dispensable.

Risk factors influencing early and late mortality after total cavopulmonary connection

OBJECTIVE

Among the later modifications of the Fontan type procedure, a significant alteration was introduced by de Leval and associates when they described the total cavopulmonary connection (TCPC). Although current results of TCPC have encouraged us to extend this procedure to high risk patients, risk factors influencing surgical outcome after TCPC have not been evaluated. We review our experiences with TCPC to identify which risk factors may have had a considerable impact on the outcome of patients undergoing TCPC and to clarify selection criteria of high-risk Fontan candidates for TCPC.

PATIENTS AND METHODS

We retrospectively reviewed the medical and surgical records of all 76 patients who underwent TCPC between July 1988 and August 2000. A cross-sectional review of these patients was undertaken.

RESULTS

There were eight early deaths and four late deaths. In a Fisher's exact test, the following variables were associated with an increased early mortality after TCPC: systemic ventricular morphology (right ventricle), ejection fraction of the systemic ventricle less than 60%, and prolonged cardiopulmonary bypass time (240 min or longer). The log-rank test demonstrated that heterotaxy syndrome, moderate to severe atrioventricular valve regurgitation, prolonged cardiopulmonary bypass time (240 min or longer), and prolonged aortic cross clamp time (70 min or longer) were associated with late mortality after TCPC. Six deaths occurred in eight (75%) patients who had six or more risk factors, whereas six deaths (9%) occurred in those who had five or fewer.

CONCLUSIONS

Patients with complex cardiac anomalies who have six or more risk factors should be excluded from TCPC candidates.

Surgical outcome of double-outlet right ventricle with subpulmonary VSD

BACKGROUND

Optimal management of double-outlet right ventricle with subpulmonary ventricular septal defect remains controversial. We reviewed our 7-year experience with patients who had this anatomic configuration.

METHODS

Between January 1992 and January 1999, 20 patients underwent an arterial switch operation (ASO group), and 12 underwent a bidirectional Glenn procedure followed by a modified Fontan in 10 (Glenn/Fontan). Mean follow-up was 23 +/- 18 months.

RESULTS

An initial palliative operation was done in 19 patients (9 in the ASO group, 10 in the Glenn/Fontan group). There were no deaths in the Glenn/Fontan group. Four patients in the ASO group died within 33 days postoperatively. Two of them had a single coronary artery, 1 had a straddling mitral valve, 1 had a hypoplastic aortic arch, and 1 had multiple ventricular septal defects. Three patients had reoperation for subaortic stenosis (n = 2) or pulmonary stenosis (n = 1) after the ASO. Four patients (3 in the ASO group, 1 in the Glenn/Fontan) required a pacemaker for postoperative complete atrioventricular block. Actuarial survival at 5 years for the entire group was 87% (70% confidence interval, 81% to 93%).

CONCLUSIONS

The ASO remains our preferred treatment for infants with double-outlet right ventricle and subpulmonary ventricular septal defect. However, associated anatomic defects are important risk factors.

Results of modified Norwood's operation for hypoplastic left heart syndrome

OBJECTIVE

The aim of the study was to analyze intermediate results of treatment of the hypoplastic left heart syndrome based on selective indication criteria.

METHODS

Between February 1997 and May 1999 38 patients with hypoplastic left heart syndrome (n=35), or with functional variant of hypoplastic left heart syndrome (n=3) were admitted to our department. Contraindications for surgery were birth weight <2500 g, diameter of ascending aorta <2 mm, severe tricuspid regurgitation persisting after initial stabilization, pulmonary regurgitation more than mild, dysfunction of the systemic right ventricle and failure to effectively resuscitate circulation before surgery.

RESULTS

Based on these criteria surgery was not indicated in 17 patients. Twenty-one infants were operated on by modified Norwood's procedure using only autologous great vessel tissue for reconstruction of systemic outflow. Overall hospital mortality was 14% (three patients). Eighteen survivors (86%) were discharged with well-balanced circulation. There was one late death (5%). Thirteen patients had already undergone the second stage (bi-directional Glenn) with no death. The mean follow-up was 13. 2+/-9.1 months (range 4-32 months). Considering both early and late events the probability of survival for the whole group (n=21) from the time of surgery was 86% at 1 month, 80% at 12 months, and it remained unchanged at 18 and 24 months of follow-up.

CONCLUSIONS

Only a limited number of European countries offer surgical treatment of hypoplastic left heart syndrome. Promising intermediate results (80% survival rate after stage I and II) achieved at our department do not only reflect overcoming the learning curve but also a selective approach to indication for surgery as well. In a country with limited resources selective approach to the patients with hypoplastic left heart syndrome is justified.

Ebstein's malformation. surgical treatment and results

Ebstein's malformation can be defined as an anomaly of the tricuspid valve existing in the setting of a right ventricular dysfunction. The technique introduced by Carpentier in 1980 is based on the concept of mobilization of the restrictive anterosuperior leaflet associated with a longitudinal plication of the inlet component of the right ventricle. From January 1980 to December 1999, 142 patients underwent surgery. The mean age was 25 +/- 15 years (1-65). Cyanosis was present in 48% and associated lesions in 64% of the patients. Patients were classified using a functional approach according to the severity of the lesions. Mild displacement of the septal leaflet, along with small size of the atrialized chamber was seen in 5% (referred to as Type A). Massive displacement of the septal leaflet, but with normal motion of the anterosuperior leaflet and an extensive atrialized chamber, was seen in 35% (Type B). In 51%, the mural (inferior) leaflet was absent, the anterosuperior leaflet was severely restricted by muscular trabeculations and very short tendinous cords, and the anterolateral papillary muscle was incorporated in the right ventricular wall. In these patients (Type C), the atrialized chamber was markedly enlarged and had dyskinetic walls. In such cases, the contractility of the distal (functional) right ventricle was also impaired, and some degree of stenosis of the tricuspid valve was present in one-fifth of them. In the most severe cases (8%), the leaflet tissue of the valve was extremely reduced and the right ventricular walls were thin and contracted poorly. This resulted in the so-called tricuspid sack arrangement (Type D). Valve replacement was needed in only 4 cases, with conservative surgery being achieved in 138 patients by means of mobilization of the anterosuperior leaflet and longitudinal plication of the inlet component of the right ventricle. Additional procedures included the use of a prosthetic ring (94 patients) and partial Glenn anastomosis (30 patients). The hospital mortality was 10%, mainly due to acute postoperative right ventricular failure. Actuarial survival was 75% at 10 years. After operation, 94% of the patients were in functional class I or II of the New York Heart Association, and 88% had no or mild tricuspid valve insufficiency as judged by echocardiography. The rate of reoperation was 9% with a mean delay of 3 years. A second repair was performed in 5 patients. Freedom from reoperation was 87% at 10 years. Sinus rhythm was present in 81%, and 8 pacemaker devices were implanted, 5 for surgically induced atrioventricular block, and 3 because of preoperative conduction disturbances. The use of the partial Glenn anastomosis was introduced recently in cases where the right ventricular contractility was severely impaired, and/or tricuspid valve repair was difficult, and/or permanent atrial fibrillation was present. In those patients with high risk, adding partial Glenn anastomosis reduced the operative mortality from 24% to 6%. Another benefit of the cavo-bipulmonary anastomosis was better functional tolerance of mild residual tricuspid valve incompetence. Those patients with the tricuspid sack arrangement had a high rate of reoperation (2/11) and valve replacement (3/11), but suffered no operative deaths. We conclude that tricuspid valvoplasty associated with longitudinal right ventricular plication is superior to valve replacement. The arrangement producing a tricuspid sack is not suitable for conservative surgery. An associated cavo-pulmonary anastomosis decreases the operative mortality in patients at high risk, and seems to preserve right ventricular function.

Factors influencing early outcome of Norwood procedure for hypoplastic left heart syndrome

OBJECTIVE

[corrected] The operative outcome of the Norwood procedure for hypoplastic left heart syndrome is still not satisfactory. Conflicting reports concern factors associated with early Norwood procedure mortality and the reasons for the instability after surgery are not sufficiently understood. The purpose of this study was to determine some perioperative factors influencing early (30 days) outcome.

METHODS

We retrospectively analyzed a group of 30 consecutive children with hypoplastic left heart syndrome (aged 5-39 days) who underwent Norwood procedure in 1997 and 1998. The following factors were considered and statistically analyzed: operative age, birth weight, operative weight, serum level of bilirubin, aminotransferases, creatinine, urea, arterial blood gasses, anatomic subgroups, ascending aorta and arch size, systemic to pulmonary modified right Blalock-Taussig shunt size, cardiopulmonary circulatory arrest time, cardiopulmonary bypass time, and delayed chest closure. Eighteen patients underwent hemi-Fontan procedure with one late death and the modified Fontan operation was performed in 16 of them (one late death).

RESULTS

The early mortality was 37%. Seven deaths (64%) occurred during the first 24 h after operation. There was a significant difference between survivals and non-survivals in: birth weight (P=0.047), operative age (P=0.016), preoperative serum level of bilirubin (P=0.044), and cardiopulmonary circulatory arrest time (P=0.006). The other assessed factors were not found to be predictors of early mortality. All 16 survivals followed up are in New York Heart Association class I or II.

CONCLUSIONS

Anatomic and functional status of the patient, as well as procedural factors are related to Norwood operation early mortality. High mortality in hypoplastic left heart syndrome after stage I surgery indicates the necessity of assessing all factors which may determine further improvement in the outcome.

[Follow-up of patients treated by conduits between the right ventricle and the pulmonary artery]

Between 1981 and 1998, 77 right ventricle-pulmonary artery conduits were implanted in 67 patients (37 boys, 30 girls, average age 6.3 years; range: 3 months to 17 years). The diagnoses were transposition of the great arteries with ventricular septal defect and obstruction of the pulmonary outflow tract (N = 22), tetralogy of Fallot (N = 16), truncus arteriosus (N = 9), double outlet right ventricle with pulmonary stenosis or atresia (N = 8) and agenesis of the pulmonary valve with pulmonary stenosis (N = 2). The implanted conduits were homografts in 50 cases (43 aortic and 7 pulmonary), 11 valved Dacron grafts, 4 valved polystans grafts and 2 non-valved conduits. The average follow-up period was 3.6 years (range: 1 month to 17 years). Early death was observed in 8 patients (12%) and late death in 6 patients (9%). The 5, 10 and 15 year survival rates were 78.4%, 65.3%, and 65.3%, respectively. The conduits had to be replaced in 10 patients (15%). The non-replacement rate of all conduits at 5, 10 and 15 years was 81.4%; 40.7% and 40.7%, respectively. The causes of replacement were pure stenosis (54.5%), pure regurgitation (9%) and mixed stenosis and regurgitation (27.2%). These results are comparable to other published series showing a 15 year survival rate of 65% and a 59% reoperation rate at 15 years. Homografts have a slightly longer life compared with valved Dacron conduits but the difference is not statistically significant.

Equivalent survival following cavopulmonary shunt: with or without the Fontan procedure

OBJECTIVES

In 1992, an analysis of our experience with the cavopulmonary shunt (CPS) demonstrated equivalent long-term survival, with or without subsequent conversion to a Fontan circulation. Before 1992 (era 1) intervention was deferred until mandated by clinical deterioration. Since 1992 (era 2), timing of both CPS and Fontan was compressed in an effort to improve survival. Survival following CPS is analyzed to ascertain whether Fontan confers any survival advantage over no further definitive intervention.

METHODS

From 1962 to 1997 inclusive, 490 patients underwent CPS, excluding those who had a CPS concomitant with a Fontan. In 55 patients the CPS was performed at or after a biventricular repair (BVR), or after a Fontan, and these patients are excluded. The 435 patients remaining followed a surgical protocol which included a subsequent BVR (n = 28), or a subsequent Fontan operation (n = 220), or no further definitive surgery (CPS only, n = 187). Between eras the mean age at surgery decreased for all procedures.

RESULTS

Long-term survival 20 years after a CPS in 435 patients is 56 +/- 5%. Survival at 20 years among the 220 patients who were subsequently converted to a Fontan circulation is 65 +/- 8% compared to 50 +/- 11% for the 187 patients who did not have a Fontan. However, most of their survival difference is because all early deaths after a CPS occurred in the non-Fontan group. Multivariable analysis demonstrated that proceeding to a Fontan did have a small survival advantage which was not evident by univariate analysis. Independent risk factors for death, at any time, are a common atrioventricular valve, or pulmonary artery banding. The era had no effect on survival.

CONCLUSIONS

The single ventricle circulation appears to have a limited durability of, an average, 30-40 years. There is a slight survival advantage in converting patients after a CPS to a Fontan circulation. A marked reduction in age at CPS and at Fontan has, as yet, not improved survival.

Bidirectional Glenn followed by total cavopulmonary connection or primary total cavopulmonary connection?

OBJECTIVE

Analysis of mortality and morbidity of patients treated by primary total cavopulmonary connection (TCPC)-Primary correction group, and comparison to patients treated by bidirectional Glenn (BDG) followed by total cavopulmonary connection-two stage TCPC group.

METHODS

Retrospective study of 123 consecutive patients who underwent 144 different types of cavopulmonary connections between 1987-1995: bidirectional Glenn 59, HemiFontan operation 10, primary total cavopulmonary connection 54, and total cavopulmonary connection completion after previous bidirectional Glenn 21. Important preoperative risk factors: age, systemic outflow obstruction, pulmonary venous obstruction, pulmonary artery (PA) hypoplasia (McGoon ratio), PA stenosis/distortion, PA mean pressure, PA vascular resistance, atrioventricular valve regurgitation, systolic and diastolic ventricular function and ventricular hypertrophy were re-evaluated according to Texas Heart Institution Scoring System in both groups. Three different preoperative risk groups were established: low risk, score (0-3) moderate risk (4,5) and high risk score (> or = 6).

RESULTS

Mean age was 85.2 month (range 16.1-229.5 months) and 106.6 months (range 42.6-178.9 months) in primary correction group and two stage TCPC group, respectively. Diagnosis was similar in both groups, majority having univentricular heart or hypoplastic one ventricle. Initial palliation (pulmonary artery banding, modified aortopulmonary shunt, coarctation repair etc.) was performed in 38 (70.3%) patients of primary correction group and in 12 (57.1%) two stage TCPC group. The mortality was 7.4% (4 out of 54) and 14.2% (3 out of 21) for primary correction and two stage TCPC group, respectively. There were two take down in the primary correction group. There was no late death in either group. Operative data and postoperative morbidity did not statistically differ in both groups.

CONCLUSION

Until 1993 bidirectional Glenn was preferred to primary total cavopulmonary connection for high risk patients. High mortality 14.2% patients of two stage TCPC group vs. 7.4% of primary correction group in patients with the same preoperative hazard led us to change our policy. We now prefer primary TCPC for all patients with functional single ventricle and surgically correctable major associated defects. High risk patients undergo TCPC with fenestration. Patients not suitable for TCPC undergo either HemiFontan operation or some type of initial palliative procedure.

Bidirectional cavopulmonary shunt in patients with anomalies of systemic and pulmonary venous drainage

BACKGROUND

Bidirectional cavopulmonary shunt and Fontan repair are now commonly performed in patients with a variety of forms of complex single ventricle, including those with anomalies of systemic or pulmonary venous return. These anomalies are ideally dealt with during bidirectional cavopulmonary shunt, thereby minimizing the complexity of the eventual Fontan procedure.

METHODS

Between March 1990 and December 1995, 36 patients with anomalous systemic or pulmonary venous drainage underwent bidirectional cavopulmonary shunt. A combination of anomalous systemic and pulmonary venous drainage was present in 12 patients, whereas 19 patients had anomalous drainage only from the systemic circulation and 5 patients had isolated anomalies of pulmonary venous return. Visceral heterotaxy syndrome was diagnosed in 18 patients. The median age at operation was 11 months, and bidirectional cavopulmonary shunt was the first surgical procedure performed in 10 of these patients. Techniques of repair are described.

RESULTS

There were two early deaths and one bidirectional cavopulmonary shunt was taken down, for mortality and failure rates not significantly different than those for all patients undergoing bidirectional cavopulmonary shunt during this time period (n = 117). At a mean follow-up of 19.9 months, there have been three late deaths and 11 patients have undergone Fontan completion. Actuarial survival was 87% at 1 year and 81% at 3 years. Among all patients undergoing bidirectional cavopulmonary shunt during this time period, neither heterotaxy syndrome nor anomalies of systemic or pulmonary venous return were significantly associated with decreased survival or poor outcome.

CONCLUSIONS

Bidirectional cavopulmonary shunt can be performed in patients with anomalous systemic or pulmonary venous drainage, including those with visceral heterotaxy syndrome, with morbidity and mortality rates that do not differ significantly from those achieved in all patients undergoing bidirectional cavopulmonary shunt. In this report, we describe our experience with this group of patients, primarily focusing on outcomes and technical issues that pertain to the use of bidirectional cavopulmonary shunt as a preparatory procedure for the extracardiac conduit Fontan operation.

An institutional experience with second- and third-stage palliative procedures for hypoplastic left heart syndrome: the impact of the bidirectional cavopulmonary shunt

OBJECTIVES

The aim of this study was to perform a retrospective analysis of an institutional experience with a consecutive series of patients with post-stage I palliation for hypoplastic left heart syndrome (HLHS).

BACKGROUND

In a recent review of 212 consecutive patients who underwent stage I operations for HLHS at our institution between 1983 and 1993, we identified risk factors related to stage I mortality. We sought to examine the outcome for these patients at subsequent palliative procedures.

METHODS

All patients who underwent stage I reconstruction between January 1983 and June 1993 and also underwent subsequent palliation at our institution were included. Seventy patients underwent palliative procedures and two underwent heart transplantation. Patient-specific factors and features of the stage II operation were analyzed for impact on stage II mortality and actuarial survival.

RESULTS

The only independent risk factor for stage II mortality was the performance of a nonfenestrated Fontan operation (p < 0.001). There were nine in-hospital deaths (69%) in the 13 patients undergoing the nonfenestrated Fontan procedure at stage II. Fifty patients underwent intermediate superior vena cava to pulmonary artery anastomosis at stage II, with 4 (8%) early deaths. Pulmonary artery augmentation was performed in 19 patients (38%) at stage II, without increased operative risk. Hypoplastic left heart syndrome anatomic subtype did not influence stage II mortality. The modified fenestrated Fontan procedure has been performed as a third stage in 32 patients whose median age was 28.7 months, with one early death at a median follow-up of 24.5 months.

CONCLUSIONS

A second-stage bidirectional cavopulmonary anastomosis for HLHS reduces second-stage mortality and improves intermediate survival. The modified fenestrated Fontan operation may then be performed as a final palliative stage with low operative risk.

Factors influencing perioperative morbidity during palliation of the univentricular heart

BACKGROUND

The modified Fontan procedure has become the treatment of choice for patients born with a univentricular heart. Although the operative mortality has steadily decreased in recent years, the hospital stay is still prolonged in many patients due to fluid retention and pleural effusions.

METHODS

We retrospectively analyzed subsets of patients undergoing the bidirectional cavopulmonary shunt (BDCPS) and modified Fontan procedure in an attempt to define factors influencing operative mortality and morbidity.

RESULTS

Multivariate analysis of 64 patients undergoing BDCPS revealed that age 6 months or less, concomitant operation, mean pulmonary pressure of 15 mm Hg or less, and mean pulmonary artery ratio of 1.8:1 or less were not statistically significant indicators of risk. Abnormal pulmonary artery architecture was a significant predictor of early and late death (p < or = 0.01). Retrospective analysis of 71 patients undergoing the modified Fontan procedure revealed no significant relationship between duration of pleural effusions and age at operation, preoperative oxygen saturation, pulmonary artery pressure, ventricular end-diastolic pressure, or prior BDCPS: Patients with important aortopulmonary collateral vessels defined by angiography had prolonged pleural drainage. Selective use of the total extracardiac conduit and the fenestrated Fontan resulted in low overall mortality with no statistical differences between subsets of patients undergoing different modifications of the Fontan procedure.

CONCLUSIONS

These data indicate that the operative risk for BDCPS or modified Fontan procedure is quite low if a procedure appropriate for the patient is selected. Abnormal pulmonary artery architecture is an important risk factor for death after the BDCPS: Aortopulmonary collateral vessels are associated with fluid retention and pleural effusions after a modified Fontan procedure. Important aortopulmonary collateral vessels should be occluded before or during the modified Fontan procedure.

Total cavopulmonary anastomosis in patients less than three years of age

BACKGROUND

As young age at modified Fontan operation was thought to be a preoperative risk factor for poorer survival, we studied early and intermediate outcome in our young patient group.

METHODS

Results in children less than 3 years of age (group I; n = 26; age range, 7 to 35 months) were compared with those in older patients (group II; n = 46; age range, 36 to 219 months). For both groups there was no significant difference with regard to preoperative pathology and hemodynamics.

RESULTS

With an overall mortality of 9.7% (7/72) there was no significant difference for both groups. Group I (n = 23) and group II (n = 42) survivors did not differ with respect to early postoperative incidence of atrial dysrhythmias, duration and volume of pleural effusion, or incidence of reoperation. Results on intermediate follow-up (group I, 31 +/- 14 months; group II, 44 +/- 20 months) demonstrated a relatively low incidence of late atrial dysrhythmias (12.3%; 8/65). Late atrioventricular valve insufficiency was significantly more frequent in group I patients.

CONCLUSIONS

With similar preoperative anatomic and hemodynamic parameters including 68% of patients with complex univentricular heart, total cavopulmonary anastomosis could be performed in patients less than 3 years of age with good clinical and hemodynamic results, as achieved in older patients.

Does an additional source of pulmonary blood flow alter outcome after a bidirectional cavopulmonary shunt?

BACKGROUND

The bidirectional cavopulmonary shunt has become an important intermediate step in the treatment of pediatric patients with single ventricle physiology who are ultimately destined for palliative surgery. We wanted to know whether there would be risks or benefits if an additional source of pulmonary blood flow was left after a bidirectional cavopulmonary shunt.

METHODS AND RESULTS

We retrospectively reviewed the medical and surgical records of all patients who underwent a bidirectional cavopulmonary shunt at the Children's Hospital of Wisconsin between January 1991 and December 1993. A total of 43 patients were identified. Anatomic diagnoses included double inlet left ventricle (14 patients), tricuspid atresia (8 patients), pulmonary atresia with intact septum (6 patients), single right ventricle (5 patients), hypoplastic left heart (3 patients), unbalanced atrioventricular septal defect (3 patients), and other complex lesions (4 patients). We then divided the patients into two groups for purposes of analysis. Group 1 had only the cavopulmonary shunt as a source of pulmonary flow (22 patients); group 2 had an additional source of pulmonary flow (21 patients). Patient age at the time of cavopulmonary shunt ranged from 6 months to 12 years, with group 1 patients being younger (31 versus 45 months, P = .05). Group 2 patients had higher postoperative central venous pressures (17.8 versus 14.1 mm Hg, P < .001) and oxygen saturations (86% versus 81%, P < .001) than did group 1 patients. There was no statistical difference between groups in the number of chest tube days or hospital days. There was 1 early death in group 1 related to severe ventricular dysfunction and 1 late death in group 2 related to sepsis. Five patients in group 2 were readmitted to the hospital for drainage of a large chylothorax compared with none in group 1 (P < .02).

CONCLUSIONS

We conclude that patients with an additional source of pulmonary blood flow after bidirectional cavopulmonary shunt have higher postoperative central venous pressures, have higher oxygen saturations, and are at risk for the late development of a chylothorax.

Influence of competitive pulmonary blood flow on the bidirectional superior cavopulmonary shunt. A multi-institutional study

BACKGROUND

It is common practice to interrupt all alternative sources of pulmonary blood flow ("competitive flow") at the time of a bidirectional superior cavopulmonary anastomosis (BCPA), although the merits of this have not been systematically studied.

METHODS AND RESULTS

We reviewed the early and medium-term clinical and hemodynamic findings in 108 consecutive patients 3 weeks to 25 years old (median, 1.9 years) undergoing BCPA at one of three institutions. Preoperatively, pulmonary blood flow was dependent on antegrade ventricular flow (n = 50), systemic-to-pulmonary shunts (n = 33), or mixed sources (n = 25). Postoperatively, competitive sources of pulmonary blood flow were left patent in 43 of 108 patients (40%). There were four early (3.7%) and four late deaths, none related to persistence of competitive flow. After BCPA, patients with competitive flow had significantly higher systemic oxygen saturations at 1 hour (85% versus 79%), 24 hours (84% versus 78%), and at hospital discharge (84% versus 78%) and required a shorter period of artificial ventilation (median, 9 versus 24 hours) and intensive care (median, 2 versus 4 days). Oxygen saturations at late follow-up (median, 2.8 years; range, 1 to 7) did not differ (83% versus 82%). No patient developed pulmonary arteriovenous malformations.

CONCLUSIONS

Competitive flow is well tolerated in the short and medium term after BCPA, and early postoperative systemic oxygen saturations are improved. The long-term influence of competitive flow on pulmonary arterial growth, arteriovenous malformation development, and ventricular function warrants investigation.