Bilateral Bidirectional Glenn Anastomosis in an Adult Patient with Aneurysmal Degeneration after an Original Blalock-Taussig Shunt / 日本心臓血管外科学会雑誌

A male patient with single ventricle pulmonary stenosis, and persistent left superior vena cava underwent original Blalock-Taussig shunt (BTS) at 2 years of age and suffered from infective endocarditis at 38 years of age. A systemic work-up detected dural arteriovenous fistula and aneurysmal dilatation of the original BTS. Cardiac catheterization and cardiac magnetic resonance imaging revealed an appropriate pulmonary vasculature for bidirectional Glenn anastomosis and sufficient antegrade pulmonary blood flow through the pulmonary valve. Bilateral bidirectional Glenn anastomosis and resection of the aneurysm of the BTS-associated aneurysm were successfully performed.

Application of bidirectional Glenn procedure in adult congenital heart disease / 中国胸心血管外科临床杂志

@#Objective    To analyze the feasibility of bidirectional Glenn procedure (BDG) in treatment of adult congenital heart disease (ACHD). Methods    From December 2004 to December 2015, 42 ACHD patients received BDG in our hospital. There were 23 males and 19 females with a mean age of 24.6±8.5 years (range: 18 to 49 years). There were functional single ventricle (FSV) in 14 patients, Ebstein’s anomaly in 11, corrected transposition of great arteries in 7, transposition of great arteries in 5, double outlet of right ventricle in 3 and tricuspid atresia in 2. Twenty patients suffered moderate or severe atrioventricular valve regurgitation (AVVR). Half of the patients were operated upon with cardiopulmonary bypass (CPB) and the others with off-pump coronary artery bypass grafting (OPCABG). Thirty-four patients underwent unilateral BDG shunt and eight bilateral BDG shunts. Concomitant procedures included correction of Ebstein’s anomaly (7 patients), atrioventricular valve replacement (7), atrial septostomy (3), ligation of patent ductus arteriosus (3), ligation of major aortopulmonary collateral arteries (2), correction of total anomalous pulmonary venous connection (1) and mitral valve repair (1). Results    The early operative mortality was 9.5% (4/42). FSV and moderate or severe AVVR were risk factors for BDG in ACHD. Early postoperative oxygen saturation increased from 78.8%±11.2% to 89.3%±6.6% (P<0.05). The follow-up time was 6-132 (41.4±33.1) months. There was no death. The heart function improved (2.7±0.5 vs. 1.9±0.4, P<0.05). Conclusion    The BDG shunt can be applied to ACHD. Although the early mortality is relatively high, the middle- and long-term results are satisfactory. The oxygen saturation increases and  the heart function improves. The life quality of patients will also improve. FSV and moderate or severe AVVR are risk factors for BDG in ACHD.

Bidirectional Glenn with interruption of antegrade pulmonary blood flow: Which is the preferred option: Ligation or division of the pulmonary artery.

We report a rare complication of massive aneurysm of the proximal ligated end of the main pulmonary artery which occurred in the setting of a patient with a functionally univentricular heart and increased pulmonary blood flow undergoing superior cavopulmonary connection. Awareness of this possibility may guide others to electively transect the pulmonary artery in such a clinical setting

The effects of different ventilator modes on cerebral tissue oxygen saturation in patients with bidirectional superior cavopulmonary connection.

Aims and Objectives: We used near‑infrared spectroscopy to document changes in cerebral tissue oxygen saturation (SctO2) in response to ventilation mode alterations after bidirectional Glenn (BDG; superior cavopulmonary connection) procedure. We also determined whether spontaneous ventilation have a beneficial effect on hemodynamic status, lactate and SctO2 when compared with other ventilation modes. Materials and Methods: 20 consecutive patients undergoing BDG were included. We measured SctO2 during three ventilator modes (intermittent positive‑pressure ventilation [IPPV]; synchronized intermittent mandatory ventilation [SIMV]; and continuous positive airway pressure + pressure support ventilation [CPAP + PSV]). We, also, measured mean airway pressure (AWP), arterial blood gases, lactate and systolic arterial pressures (SAP). Results: There was no change in SctO2 in IPPV and SIMV modes; the SctO2 measured during CPAP + PSV and after extubation increased significantly (60.5 ± 11, 61 ± 10, 65 ± 10, 66 ± 11 respectively) (P < 0.05). The differences in the SAP measured during IPPV and SIMV modes was insignificant; the SAP increased significantly during CPAP + PSV mode and after extubation compared with IPPV and SIMV (109 ± 11, 110 ± 12, 95 ± 17, 99 ± 13 mmHg, respectively) (P < 0.05). Mean AWP did not change during IPPV and SIMV modes, mean AWP decreased significantly during CPAP + PSV mode (14 ± 4, 14 ± 3, 10 ± 1 mmHg, respectively) (P < 0.01). Conclusions: The SctO2 was higher during CPAP + PSV ventilation and after extubation compared to IPPV and SIMV modes of ventilation. The mean AWP was lower during CPAP + PSV ventilation compared to IPPV and SIMV modes of ventilation.

Two Infant Cases with Pulmonary Atresia, Intact Ventricular Septum, Right Ventricle-Dependent Coronary Circulation, and Myocardial Ischemic Symptoms / 日本心臓血管外科学会雑誌

We describe two cases with pulmonary atresia, intact ventricular septum (PA/IVS), and right ventricle-dependent coronary circulation, who suffered from myocardial ischemic symptoms. Case 1 : A female infant diagnosed with PA/IVS during the fetal period was born after 40 weeks of gestation, weighing 3,078 g. Aortography demonstrated that the right coronary artery (RCA) was interrupted at the proximal segment, and the left coronary artery (LCA) did not show any stenosis. Right ventriculogram revealed sinusoidal connections filling the distal part of the right coronary artery and fistulous communications to the left anterior descending artery. Temporary ST segmental depression in ECG during milk feeding or crying improved spontaneously with time. Bidirectional Glenn shunt (BDG) was performed at 3 months old, and she underwent Fontan repair at 4 years old. She is doing well with no evidence of myocardial ischemic change. Case 2 : A female infant was born after 39 weeks of gestation, weighing 3,062 g. Aortography demonstrated that the RCA was interrupted at the middle segment, and the distal area depended on the right ventricle. LCA ostium at the ascending aorta was absent. Multiple sinusoidal connections were seen in the right ventricular myocardium with filling of the LCAs but no reflux into the aortic sinuses. After ventricular tachycardia occurred at 2 months old, left ventricular function deteriorated. BDG with ligation of the arterial duct was performed at age 3 months. The arterial blood pressure was 76/53 (62) mmHg and pressure in SVC was 21 mmHg immediately after the operation. However, arterial oxygen saturation, right atrium venous oxygen saturation and left ventricular ejection fraction were 50%, 16%, and 10%, respectively. Although extracorporeal membrane oxygenation was established for circulatory and myocardial oxygenation support on the postoperative day 2, her left ventricular function did not recover and she died on postoperative day 5. It is difficult to rescue such a case in which almost all coronary circulation depends on the right ventricle filled with desaturated blood.

Glenn bidireccional: resultados y análisis de factores de riesgo en una experiencia de 5 años / Bidirectional Glenn: Outcomes and risk factor analysis in a 5 years' experience

Objetivo: La anastomosis de Glenn es un procedimiento paliativo en pacientes con ventrículo único. Si bien se asocia a baja morbimortalidad, el objetivo es exponer los resultados en cirugía de Glenn y analizar los factores de riesgo en nuestra población. Métodos: Estudio retrospectivo de pacientes con cirugía de Glenn entre 2005 y 2009. Se registraron variables demográficas, tipo de ventrículo único, cirugía previa, método de cirugía y evolución en postoperatorio. Se efectuó un análisis estadístico univariado y multivariado para identificar factores de riesgo de mortalidad y/o de internación prolongada (Stata 9.0). Resultados: Se operaron 101 pacientes, 87 con Glenn bidireccional y 14 con Glenn bilateral. Edad mediana 15 meses (2.5-108), peso 8.5 kg (4.2-27). El 74% tenían cirugía previa, en 54 se realizó algún procedimiento asociado al Glenn y en 4 se dejó una fuente adicional de flujo pulmonar. La mediana de internación fue de 8 días (2-97). El 35% presentó complicaciones postoperatorias. No encontramos asociación entre edad, peso o cirugías previas y mortalidad. Tampoco entre tiempo de bomba y <

Objective: Bidirectional Glenn shunt is a palliative surgical procedure in patients with single ventricle. Although morbimortality in this surgery is low, risk factors have been described. The purpose of this study is to report our outcomes in Glenn surgery, identifying mortality risk factors in our population. Methods: Retrospective study between 2005 and 2009. Age, weight, previous surgery, surgical procedure, and postoperative condition were analyzed. Results are reported as median and rank, or absolute values and percentage. Uni and multivariate analysis was made to identify risk factors of mortality and/or prolonged hospitalization (Stata 9.0). Results: One hundred and one patients were operated; 87 bidirectional Glenn and 14 bilateral Glenn. Median age 15 months (2.5-108), median weight 8.5 kg (4.2-27), and 74% of them with previous surgery. In 54 patients an associated procedure was performed simultaneously, only in 4 additional pulmonary blood flow was left. Median hospitalization was 8 days (2-97). Thirty-five percent of the patients presented complications. No association between age, weight, pulmonary hypertension, cardiopulmonary bypass, cross clamping, associated procedures or Glenn bilateral with mortality or morbidity was found. Overall mortality was 3.9%. Conclusion: Mortality was similar to other centers, but morbidity in this group of patients is high. No independent risk factors associated with morbidity or mortality were identified.

Numerical study on bilateral bidirectional Glenn shunt / 医用生物力学

Objective To predict the influence of connecting position between left superior vena cava (LSVC) and pulmonary artery on bilateral bidirectional Glenn (BBDG) shunt by numerical simulation. Methods Firstly, a 3D anatomical geometrical model was reconstructed by the medical images of a hypoplastic left heart syndrome (HLHS) patient with LSVC. Secondly, based on haptic deformations, several computational models were virtually generated, and computational fluid dynamics (CFD) numerical simulations were conducted using finite volume method. Finally, hemodynamic parameters were analyzed and evaluated. Results Flow recirculation was observed in the pulmonary artery between the LSVC and right superior vena cava (RSVC). The diameter of RSVC was defined as D. Varying the distance between LSVC and RSVC from 2D to 3.5D resulted in the least energy dissipation at 3D and the most at 2D. The blood flow rate ratios of left pulmonary artery to right pulmonary artery (LPA/RPA) ranged from 0.65-1.11. Conclusions Too close distance between LSVC and RSVC would bring out unfavorable hemodynamic distributions and consume more energy in the treatment of BBDG shunt. This study is of significance for surgeons to evaluate the optimal Fontan options in the treatment of HLHS accompanied by LSVC.

Clinical efficacy of bidirectional Glenn shunt with non-cardiopulmonary bypass / 中国医师进修杂志

ObjectiveTo investigate the clinical efficacy of bidirectional Glenn shunt with noncardiopulmonary bypass(CPB) for treating congenital heart disease.MethodsThe clinical data of forty-four patients receiving bidirectional Glenn shunt from August 2005 to August 2011 were analyzedretrospectively,twenty-three cases of which were treated by bidirectional Glenn shunt with non-CPB (non-CPB group) and twenty-one with CPB (CPB group).The duration of ventilator-assisted breathing,chest drainage volume,amount of blood product usage,postoperative hospital stay and pulse oxygen saturation (SpO2) before leaving the hospital were compared and analyzed between two groups.ResultsForty-four patients were all cured.The duration of ventilator-assisted breathing,chest drainage volume and the amount of blood product usage of non-CPB group were less than those of CPB group [ (4.5 ± 1.3 ) h vs.(6.7 ± 1.5 ) h,(4.6 ± 1.4 ) ml/kg vs.(7.7 ± 3.1 ) ml/kg,( 221.8 ± 97.6 ) ml vs.( 423.4 ± 149.7 ) ml,P ＜ 0.05 ].There was no significant difference of the postoperative hospital stay and SpO2 before leaving the hospital between non-CPB group and CPB group[ (7.4 ± 2.3 ) d vs.(7.8 ± 1.9) d,0.91 ± 0.05 vs.0.88 ± 0.39,P ＞ 0.05 ].Conclusion Bidirectional Glenn shunt with non-CPB is a safe and feasible surgical approach,which is worthy of promotion.

Clinical application of bidirectional Glenn shunt without extracorporeal circulation for complicated congenital heart disease in children / 中国医师进修杂志

ObjectiveTo evaluate the clinical application of bidirectional Glenn shunt without extracorporeal circulation(ECC) on treatment of children with complicated congenital heart disease (CHD).MethodsForty-six patients with complicated CHD(without ECC group) underwent bidirectional Glenn shunt without ECC,and 40 patients with complicated CHD (with ECC group) underwent bidirectional Glenn shunt with ECC.The therapeutic effect was compared between two groups.ResultsThere was no operative mortality in two groups.The pulmonary artery pressure in without ECC group was significantly lower than that in with ECC group [( 16.7 ± 1.2) mm Hg ( 1 mm Hg =0.133 kPa) vs.( 18.9 ± 1.0) mm Hg,t =4.686,P=0.026 ].Duration of respirator assistance after operation in without ECC group was significantly lower than that in with ECC group [ ( 12.2 ± 2.7) h vs.( 19.2 ± 2.8) h,t =2.972,P =0.041 ].There was no significant difference in saturation of blood oxygen and the rate of chylothorax after operation between two groups (P＞0.05).The symptoms and signs including cyanosis and breath were markedly alleviative in all patients.ConclusionBidirectional Glenn shunt without ECC is an effective and safe method for complicated CHD.

A Case of Venous Aneurysm of the Superior Vena Cava Following Systemic-to-Pulmonary Artery Shunt / 日本心臓血管外科学会雑誌

A 13-year-old girl with asplenia syndrome who previously had undergone left subclavian-to-pulmonary artery shunt after removal of a cavopulmonary shunt with interposition of a short segment of the left superior vena cava was admitted for congestive heart failure. Angiography revealed aneurysmal dilatation of the left superior vena cava. Percutaneous coil embolization of the shunt was successfully performed and the venous aneurysm was diminished. Interposition of a venous component in systemic-to-pulmonary artery shunt should be avoided even after removing a cavopulmonary shunt.

Surgical Treatment for Asplenia Syndrome / 日本心臓血管外科学会雑誌

Recently, modified Fontan operation is being used for asplenia syndrome. We reviewed 24 patients with asplenia syndrome who underwent surgical intervention. Eleven (45.8%) of them had total anomalous pulmonary venous connection (TAPVC) and 6 of these were accompanied by pulmonary venous obstruction (PVO). Surgical results were poor in the PVO group. In 4 cases with open heart palliation, that is atrium-common pulmonary venous chamber anastomosis, there were 2 operative deaths, 1 late death, and 1 survival. In 18 cases without PVO, statistical analysis (Fisher's exact probability) showed that pulmonary atresia (PA) was a definite risk factor for Fontan candidates (<i>p</i><0.05). In 9 cases with pulmonary stenosis (PS group), there were 5 candidates for the Fontan type operation. In the other 9 cases with PA (PA group) there were no candidates for the Fontan type operation. Only the size and the morphology of the pulmonary artery were significant factors (<i>p</i><0.05) for candidates of the Fontan type operation among the risk factors such as size and morphology of the pulmonary artery, pulmonary vascular resistance and pressure, atrioventricular valve regurgitation, and single ventricular function. Finally, in these 24 cases, there were only 5 candidates (20.8%) for a Fontan type operation. In conclusion, in order to increase candidates for Fontan precedures, it is important to maintain an adequate pulmonary blood flow. Earlier PDA division and pulmonary arteries plasty are the most importantin PA group. In both groups pulsatile bidirectional cavopulmonary shunts may be useful to increase effective pulmonary blood flow without ventricular volume overload, which leads to atrioventricular valve regurgitation.