Hostname: page-component-8448b6f56d-xtgtn Total loading time: 0 Render date: 2024-04-25T06:13:13.830Z Has data issue: false hasContentIssue false
  • English
  • Français

Bidirectional Glenn for residual outflow obstruction in Tetralogy of Fallot

Published online by Cambridge University Press:  23 May 2019

Kamal Saleem ,
Iftikhar Ahmed ,
Mehboob Sultan ,
Intisar ul Haq ,
Umair Younus  and
William M Novick
Kamal Saleem
Affiliation:
Department of Pediatric Cardiac Surgery, Armed Forces Institute of Cardiology/National Institute of Heart Diseases, The Mall, Rawalpindi, Pakistan
Iftikhar Ahmed
Affiliation:
Department of Pediatric Cardiac Anesthesia, Armed Forces Institute of Cardiology/National Institute of Heart Diseases, The Mall, Rawalpindi, Pakistan
Mehboob Sultan
Affiliation:
Department of Pediatric Cardiology, Armed Forces Institute of Cardiology/National Institute of Heart Diseases, The Mall, Rawalpindi, Pakistan
Intisar ul Haq
Affiliation:
Department of Pediatric Cardiac Surgery, Armed Forces Institute of Cardiology/National Institute of Heart Diseases, The Mall, Rawalpindi, Pakistan
Umair Younus
Affiliation:
Department of Pediatric Cardiac Anesthesia, Armed Forces Institute of Cardiology/National Institute of Heart Diseases, The Mall, Rawalpindi, Pakistan
William M Novick*
Affiliation:
University of Tennessee Health Science Center-Global Surgery Institute, Memphis, TN, USA William Novick Global Cardiac Alliance, Memphis, TN, USA
*
Author for correspondence: William M Novick, 1750 Madison Ave., Suite 500, Memphis, TN 38104, USA. Tel: +1-901-438-9413; E-mail: bill.novick@cardiac-alliance.org
Get access Rights & Permissions [Opens in a new window]

Abstract

Background:

Residual right ventricular outflow obstruction during Tetralogy of Fallot repair necessitates peri-operative revision often requiring trans-annular patch with its negative sequels. Bidirectional Glenn shunt in this setting reduces trans-pulmonary gradient to avoid revision.

Methods:

Bidirectional Glenn shunt was added during Tetralogy repair in patients with significant residual obstruction. A total of 53 patients between January, 2011 and June, 2018 were included. Final follow-up was conducted in July, 2018.

Results:

Mean age at operation was 5.63±3.1 years. Right to left ventricular pressure ratio reduced significantly (0.91±0.09 versus 0.68±0.05; p<0.001) after bidirectional Glenn, avoiding revision in all cases. Glenn pressures at ICU admission decreased significantly by the time of ICU discharge (16.7±3.02 versus 13.5±2.19; p<0.001). Pleural drainage ≥ 7 days was seen in 14 (26.4%) patients. No side effects related to bidirectional Glenn-like facial swelling or veno-venous collaterals were noted. Mortality was 3.7%. Discharge echocardiography showed a mean trans-pulmonary gradient of 32.11±5.62 mmHg that decreased significantly to 25.64±5 (p<0.001) at the time of follow-up. Pulmonary insufficiency was none to mild in 45 (88.2%) and moderate in 6 (11.8%). Mean follow-up was 36.12±25.15 months (range 0.5–90). There was no interim intervention or death. At follow-up, all the patients were in NYHA functional class 1 with no increase in severity of pulmonary insufficiency.

Conclusion:

Supplementary bidirectional Glenn shunt significantly reduced residual right ventricular outflow obstruction during Tetralogy of Fallot repair avoiding revision with satisfactory early and mid-term results.

Keywords

Bi-directional GlennTetralogy of Fallottrans-annular patchpulmonary valveinsufficiency
Type
Original Article
Information
Cardiology in the Young , Volume 29 , Issue 5 , May 2019 , pp. 684 - 688
Copyright
© Cambridge University Press 2019 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Bouzas, B, Kilner, PJ, Gatzoulis, MA. Pulmonary regurgitation: not a benign lesion. Eur Heart J 2005; 26: 433–439.CrossRefGoogle ScholarPubMed
Puranik, R, Tsang, V, Lurz, P, et al. Long-term importance of right ventricular outflow tract patch function in patients with pulmonary regurgitation. J Thorac Cardiovasc Surg 2012; 143: 1103–1107.CrossRefGoogle ScholarPubMed
Vida, VL, Angelini, A, Guariento, A, et al. Preserving the pulmonary valve during early repair of tetralogy of Fallot: anatomic substrates and surgical strategies. J Thorac Cardiovasc Surg 2015; 149: 1358–1363.CrossRefGoogle ScholarPubMed
Stewart, RD, Backer, CL, Young, L, Mavroudis, C. Tetralogy of Fallot: results of a pulmonary valve-sparing strategy. Ann Thorac Surg 2005; 80: 1431–1439.CrossRefGoogle ScholarPubMed
Bové, T, François, K, Van De Kerckhove, K, et al. Assessment of a right-ventricular infundibulum-sparing approach in transatrial–transpulmonary repair of tetralogy of Fallot. Eur J Cardiothorac Surg 2012; 41: 126–133.Google ScholarPubMed
Kaushal, SK, Radhakrishanan, S, Dagar, KS, et al. Significant intraoperative right ventricular outflow gradients after repair for tetralogy of Fallot: to revise or not to revise? Ann Thorac Surg 1999; 68: 1705–1713.CrossRefGoogle ScholarPubMed
Logoteta, J, Dullin, L, Hansen, JH, et al. Restrictive enlargement of the pulmonary annulus at repair of tetralogy of Fallot: a comparative 10-year follow-up study. Eur J Cardiothorac Surg 2017; 52: 1149–1154.CrossRefGoogle ScholarPubMed
Ascuitto, R, Ross-Ascuitto, N, Wiesman, J, DeLeon, S. Bidirectional Glenn shunt as an adjunct to surgical repair of congenital heart disease associated with pulmonary outflow obstruction: relevance of the fluid pressure drop–flow relationship. Pediatr Cardiol 2008; 29: 910–917.CrossRefGoogle ScholarPubMed
Zias, EA, Mavroudis, C, Cook, KE, Makarewicz, AJ, Backer, CL, Hernandez, JM. The effect of pulmonary circulation hemodynamics on right ventricular unloading via the bidirectional Glenn shunt: Implications for congenitally corrected transposition repair. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2003; 6: 27–32.CrossRefGoogle ScholarPubMed
Mavroudis, C, Backer, CL, Kohr, LM, et al. Bidirectional Glenn shunt in association with congenital heart repairs: the 11/2 ventricular repair. Ann Thorac Surg 1999; 68: 976–981.CrossRefGoogle Scholar
Mavroudis, C, Backer, CL. Physiologic versus anatomic repair of congenitally corrected transposition of the great arteries. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2003; 6: 16–26.CrossRefGoogle ScholarPubMed
Malhotra, SP, Reddy, VM, Qiu, M, et al. The hemi-mustard/bidirectional Glenn atrial switch procedure in the double-switch operation for congenitally corrected transposition of the great arteries: rationale and midterm results. J Thorac Cardiovasc Surg 2011; 141: 162–170.CrossRefGoogle ScholarPubMed
Hofferberth, SC, Nathan, M, Marx, GR, et al. Valve-sparing repair with intraoperative balloon dilation in tetralogy of Fallot: midterm results and therapeutic implications. J Thorac Cardiovasc Surg 2018 Mar; 155: 1163–1173.CrossRefGoogle ScholarPubMed
Awori, MN, Leong, W, Artrip, JH, O’donnell, C. Tetralogy of Fallot repair: optimal z-score use for transannular patch insertion. Eur J Cardiothorac Surg 2013; 43: 483–486.CrossRefGoogle ScholarPubMed
Sandoval, N, Carreño, M, Novick, WM, et al. Tetralogy of Fallot repair in developing countries: International quality improvement collaborative. Ann Thorac Surg 2018 Nov; 106: 1446–1451.CrossRefGoogle ScholarPubMed
Latus, H, Gummel, K, Rupp, S, et al. Beneficial effects of residual right ventricular outflow tract obstruction on right ventricular volume and function in patients after repair of tetralogy of Fallot. Pediatr Cardiol 2013; 34: 424–430.CrossRefGoogle ScholarPubMed
Freling, HG, Willems, TP, van Melle, JP, et al. Effect of right ventricular outflow tract obstruction on right ventricular volumes and exercise capacity in patients with repaired tetralogy of Fallot. Am J Cardiol 2014; 113: 719–723.CrossRefGoogle ScholarPubMed
Hussain, A, Saleem, K, Inam-ullah, Ahmed I, Younus, U, Rashid, A. Bidirectional Glenn shunt without cardiopulmonary bypass. J Coll Physicians Surg Pak 2009; 19: 682–685.Google ScholarPubMed
Kogon, BE, Plattner, C, Leong, T, Simsic, J, Kirshbom, PM, Kanter, KR. The bidirectional Glenn operation: a risk factor analysis for morbidity and mortality. J Thorac Cardiovasc Surg 2008; 136: 1237–1242.CrossRefGoogle ScholarPubMed
Al Habib, HF, Jacobs, JP, Mavroudis, C, et al. Contemporary patterns of management of tetralogy of Fallot: data from the Society of Thoracic Surgeons Database. Ann Thorac Surg 2010; 90: 813–820.CrossRefGoogle ScholarPubMed
Sarris, GE, Comas, JV, Tobota, Z, Maruszewski, B. Results of reparative surgery for tetralogy of Fallot: data from the European Association for Cardio-Thoracic Surgery Congenital Database. Eur J Cardiothorac Surg 2012; 42: 766–774.CrossRefGoogle ScholarPubMed