Bidirectional Glenn shunt without cardiopulmonary bypass

From April 2002 to March 2005, 18 patients having undergone bidirectional Glenn shunt (BDG) without cardiopulmonary bypass (CPB) [off-pump BDG] were retrospectively reviewed. During BDG anastomosis, a temporary bypass was established between superior vena cava (15) or innominate vein (3) and main pulmonary artery (16) or right atrium (2). Hemodynamics and oxygenation were maintained well throughout the temporary bypass time. There was no emergent use of CPB. Mean transpulmonary pressure gradient immediately after and 24 hours after the BDG were 6.7 and 5.6 mmHg, respectively. Echocardiography showed mild flow turbulence at the anastomosis in 1 case. This simple and inexpensive technique provided good surgical view with stable hemodynamics enabling satisfactory BDG in selected cases. Furthermore, it could avoid adverse effects of CPB such as lung injury and possible blood transfusion. This experience would encourage off-pump BDG combined with more challenging procedures.     

非体外循环下行双向格林手术(附58例报道)

目的　总结非体外循环下行双向格林手术的体会。方法　 2 0 0 0年 5月至 2 0 0 1年 9月 ,在非体外循环下行双向格林手术 5 8例。年龄 (3 5 4± 1 5 9)岁 ,体重 (13 6± 4 0 )kg。上腔静脉与右心耳插管临时转流 ,自上腔静脉入右房处横断上腔静脉 ,缝闭近心端 ,应用可吸收线端侧吻合远心端与右肺动脉 ,前壁用自体心包片加宽。结果　全组无手术死亡 ,术后并发乳糜胸 4例 ,一过性昏迷 1例。腔静脉阻断 (48± 15 )min ,术前氧饱和度 0 75± 0 0 9,肺动脉压 (12 8± 2 3)mmHg(1mmHg=0 133kPa) ;术毕氧饱和度 0 93± 0 0 5 ,肺动脉压 (16 5± 2 9)mmHg,胸腔及心包引流液 (145± 10 3)ml,呼吸机辅助 (13± 7)h ,住院 (10± 5 )d。结论　非体外循环下行双向格林手术是一种安全、可靠的术式。对于难以解剖根治或一期生理矫治的肺血少的复杂先天性心脏病 ,该术式是一种良好的手术方法。     

Bidirectional glenn operation in infancy

The ideal age for bidirectional Glenn shunt (BDGS) as the first stage of staged Fontan is still not clear. Because of the concerns regarding relatively high pulmonary vascular resistance during infancy, many centres would bridge through a systemic to pulmonary artery shunt in this age group. Patients and Methods We did a retrospective analysis of 28 infants who had undergone bidirectional Glenn shunt at our institute from February 200. Results The mean age was 5 months (2.5–11) and the mean weight was 6.5 Kg (3.4–8.7). Boys dominated the group (25∶3). 7 infants had previous procedures. In 3 patients, BDGS was done as a salvage procedure. Formal Cardiopulmonary bypass (CPB) was used in all but 4 patients, in whom a right heart bypass was used. Superior Vena Cava (SVC) or innominate vein was cannulated in 12 patients and the rest were managed with temporary occlusion of SVC under deep hypothermic low flow bypass. 9 infants had bilateral BDGS. The main pulmonary artery was interrupted in 12 and atrial septectomy was done in 10 patients. Additional procedures with BDGS included Patent Ductus Arterious (PDA) interruption, Blalock Taussig (BT) shunt interruption, Left pulmonary arterioplasty, Stansel procedure and redo TAPVC repair. The mean SVC pressure post operatively was 14 (10–24) and only 2 patients needed pulmonary vasodilators in the post-oprative period. There is only one mortality in this series and the duration of chest tube drainage and Intensive Care Unit (ICU) stay is comparable with the older age group. Conclusion BDGS can be performed safely in infants more than 2 months of age electively or as a salvage procedure. It helps to avoid one step in the form of aortopulmonary shunt and hence the ventricular volume overload associated with it. Further studies are required to establish the growth potential of pulmonary arteries following an early BDGS. Presented at the 50th annual meeting of IACTS, New Delhi, Feb. 2004.     

Bidirectional Glenn procedure without cardiopulmonary bypass

BACKGROUND: Whether the bidirectional Glenn procedure is better performed without the support of cardiopulmonary bypass is still a matter for debate. In this paper we discuss the indications and methods for bidirectional Glenn shunt without cardiopulmonary bypass. METHODS: Twenty patients with complex cyanotic congenital heart defects underwent a bidirectional Glenn shunt without cardiopulmonary bypass between May 2000 and August 2002. There were 10 male and 10 female patients, the mean age was 2.7 +/- 2.6 years (range, 3 months to 11 years), and the mean weight was 11.0 +/- 6.0 kg (range, 4.5 to 32 kg). The mean transcutaneous oxygen saturation was 74.3% +/- 5.7% before the operation. The Glenn shunt was performed under venoatrial or venopulmonary shunt. RESULTS: All patients survived. Mean superior vena cava clamping time was 24.3 +/- 4.7 minutes, and mean vena cava pressure was 26.9 +/- 5.5 mm Hg during clamping. There were no postoperative neurologic complications. Follow-up echocardiography showed functioning Glenn shunts without any obstruction at the anastomosis. CONCLUSIONS: The adverse effects of cardiopulmonary bypass could be eliminated by this method. This is an advantage during the postoperative recovery, but patients should be strictly chosen.     

Bidirectional glenn shunt surgery using lepirudin anticoagulation in an infant with heparin-induced thrombocytopenia with thrombosis

There are few reports of the management of pediatric patients with heparin-induced thrombocytopenia (HIT) requiring cardiac surgery using currently available anticoagulants. We report a case of an infant with HIT requiring a bidirectional Glenn shunt who was successfully managed using lepirudin (r-hirudin, Refludan; Aventis, Bridgewater, NJ). Dosing and monitoring of anticoagulation were difficult, and we suggest caution in the use of lepirudin for cardiac surgery unless reliable monitoring of the degree of anticoagulation becomes available.     

Bidirectional superior cavo-pulmonary anastomosis without cardiopulmonary bypass

The bidirectional superior cavopulmonary anastomosis is an important intermediate palliation in patients with a structurally or functionally univentricular heart. There is an increasing trend to perform this anastomosis without cardiopulmonary bypass. In this review, we present our preferred technique of performing this operation in a safe, simple, inexpensive and reproducible manner.     

Novel techniques of bidirectional Glenn shunt without cardiopulmonary bypass

Background. We report novel techniques of performing bidirectional Glenn shunt (BDG) without cardiopulmonary bypass (CPB).

Methods. Five cases of single ventricle and pulmonary stenosis (PS) complex were taken up for BDG without CPB. The criteria for case selection were an unrestrictive atrial septal defect (ASD), no atrioventricular (AV) valve regurgitation, and no other intracardiac defects requiring correction. A temporary shunt was established between the superior vena cava (SVC) and contralateral branch pulmonary artery (PA) for venous drainage during SVC clamping for BDG anastomosis in four cases. In case 5, a shunt was put between the SVC and right atrium (RA) for venous drainage, and modified Blalock Taussig shunt and patent ductus arteriosus (PDA) were left open until the completion of the BDG.

Results. Central venous pressure (CVP) increased to a mean of 22.4 mm Hg during SVC clamping, with improvement of oxygen (O₂) saturation from 62.4% to 82.4%. After Glenn shunt, CVP and O₂ saturation maintained at 13.2 mm Hg and 87.4%, respectively. Postoperatively, there were no neurological abnormalities and no hospital mortality.

Conclusions. Our technique provides an excellent venous drainage with improvement of O₂ saturation during SVC clamping. It avoids problems related to CPB and economy. It is easily reproducible, with excellent results in a selected group of patients without compromising the completeness of repair.     

Combined endocardiectomy and bidirectional glenn shunt for right ventricular endomyocardial fibrosis

We report the case of a young African woman with a history of right ventricular failure. Image studies suggested endomyocardial fibrosis affecting only the right side of the heart. The right ventricle was extremely small and restricted. The surgical approach entailed endocardectomy and a bidirectional cavopulmonary shunt to improve weaning off bypass and postoperative recovery, both of which were successfully achieved.     

Bidirectional cavopulmonary shunt using the azygos vein

A case is described in which a two-year-old boy, diagnosed with common atrioventricular canal, pulmonary atresia, major aortopulmonary collateral artery, asplenia, and situs inversus, underwent palliative operations for the following: unifocalization of the right major aortopulmonary collateral artery, right ventricle-to-pulmonary artery shunt, and pulmonary artery plasty. Upon completion of the bidirectional cavopulmonary shunt operation, we addressed the stenotic lesions of the superior vena cava and left pulmonary artery, and a markedly expanded azygos vein. During this operation, the superior vena cava was divided and we performed cavopulmonary shunting with the azygos vein.     

Ventriculo-ureteral shunt without nephrectomy.

Some patients with hydrocephalus cannot be adequately treated with either ventriculo-peritoneal or ventriculo-atrial shunts. Ventriculo-ureteral (VU) shunts are seldom considered in this group of patients because of the belief that nephrectomy is an essential part of the procedure. We report a case in which a VU shunt was performed with direct ureteral re-implantation and we suggest that a VU shunt is a reasonable alternative for the treatment of a patient with difficult-to-manage hydrocephalus.     

Extracardiac Fontan operation without cardiopulmonary bypass

AIM: The avoidance of cardiopulmonary bypass and aortic cross-clamping in patients possessing single ventricular physiology has potential advantages including preservation of ventricular and pulmonary functions; early extubation, decreased incidence of pleural effusions and decreased requirement of inotropic agents and blood products. In this study, we assessed the postoperative outcome of patients who have undergone extracardiac Fontan operation performed without cardiopulmonary bypass. METHODS: Between March 1999 and August 2002, 10 consecutive patients (6 males and 4 females) underwent extracardiac Fontan operation without cardiopulmonary bypass. The age of patients ranged between 1.5 to 12 (5.2+/-3.1) years. All the patients requiring any intracardiac intervention were excluded from the study. Previous operations of the patients were modified Blalock-Taussig shunt procedure in 3 patients, bidirectional cavopulmonary shunt operation in 2 patients and pulmonary arterial banding in 1 patient. All operations were performed without cardiopulmonary bypass. Bidirectional cavopulmonary anastomosis was performed by using a transient external shunt constructed between the superior vena cava and right atrium. An appropriate sized tube graft was anastomosed to the inferior surface of right pulmonary artery. Finally, inferior vena cava to tube grafts anastomosis was performed with the aid of another external shunt constructed between inferior vena cava and right atrium. During the procedure central venous pressure, blood pressure and arterial oxygen saturation levels were continuously monitored and recorded. RESULTS: The mean intraoperative Fontan pressure was 16.1+/-2.75 mmHg. Intraoperative fenestration was required in 4 patients with a Fontan pressure above 18 mmHg. There were no intra and postoperative deaths. Three patients required mild doses of inotropic support during the postoperative period. All patients were weaned off mechanical ventilation within 24 h. The mean arterial oxygen saturation raised from 74.5+/-4.2% to 93.5+/-2%. Arterial oxygen saturation was 95+/-0.6% in 6 patients without fenestration and 91.2+/-0.5% in 4 patients with fenestration (P=0.001). All patients were in sinus rhythm postoperatively. Only 2 patients required blood transfusion. Two patients suffered from prolonged pleural effusion (more than 7 days). The mean intensive care unit and hospital stay periods were 3.3+/-1.5 and 15.4+/-5.3 days, respectively. CONCLUSIONS: The extracardiac Fontan operation performed without cardiopulmonary bypass provides good results in short and midterm follow-up periods with improved postoperative hemodynamics.     

Surgical myocardial revascularization without cardiopulmonary bypass

BACKGROUND: Though coronary artery bypass grafting (CABG) without cardiopulmonary bypass is being performed with increasing frequency, in the absence of adequate angiographic follow-up, safety, reproducibility, and efficacy of the procedure remain doubtful. In this prospective study, we report the results obtained by 100% angiographic follow-up of 96 consecutive patients. METHODS: A total of 96 patients (age range 33 to 76 years) underwent CABG without cardiopulmonary bypass. Single vessel disease was present in 46 (47.9%) patients, double vessel disease in 31 (32.3%), and triple vessel disease in 19 (19.8%) patients. All patients were operated through a standard midsternotomy and an optimal combination of pharmacological and mechanical methods were used to restrict cardiac movements during anastomosis. All patients underwent coronary angiography before discharge from the hospital. RESULTS: A total of 160 grafts were placed (range 1 to 4 grafts per patient, average 1.7+/-0.3 grafts per patient). A single graft was placed in 46 patients, double grafts in 38, triple grafts in 10, and quadruple grafts in 2 patients. Various grafts included pedicled left internal mammary artery (LIMA) (n = 95), free LIMA (n = 1), right internal mammary artery (n = 14), radial artery (n = 24), right gastroepiploic artery (n = 5), and saphenous vein grafts (n = 21). Operative mortality was 1.0% (1 of 96). Two patients required reoperation for excessive bleeding. Mean hospital stay was 5.7+/-1.2 days. Overall angiographic patency was 95.0% with LIMA patency of 97.9% (93 of 95). One patient with block in midsegment of LIMA was reoperated using cardiopulmonary bypass. Follow-up ranged from 4 to 17 months (mean 8.2+/-3.1 months). Two patients (one with narrowed LIMA to left anterior descending artery anastomosis, and one with patent anastomosis) had residual angina. CONCLUSIONS: Coronary artery bypass grafting without cardiopulmonary bypass is a reproducible, effective, and safe option in selected group of patients. A conscientious approach in patient selection and route of operation is required.