Is More Better or Is Less More?

Abstract

In staged palliation for single-ventricle congenital heart disease, the debate over whether adding or maintaining an additional source of pulmonary blood flow (APBF) at the time of the superior cavopulmonary connection (SCPC) has waged for several decades. All studies addressing this topic had retrospective single-center designs with heterogeneous patient populations. These studies commonly use surgeon preference as the indication to add, maintain, or eliminate APBF at SCPC. In one metaanalysis, the methodology used for some of these analyses was judged to be poor. 1 Alghamdi A.A. Bidirectional Glenn with additional pulmonary blood flow: systematic review and evidence-based recommendations. J Card Surg. 2015; 30: 724-730 Crossref PubMed Scopus (5) Google Scholar Not surprisingly, the findings from this collective work have been inconsistent. For example, proponents of adding APBF to SCPC cite higher peripheral oxygen saturations (Spo2) after the SCPC, improved pulmonary artery (PA) growth during the interval between SCPC and Fontan completion, and intentionally delaying Fontan surgery to allow for somatic growth as benefits of this strategy. 2 Ferns S.J. El Zein C. Multani K. et al. Is Additional pulsatile pulmonary blood flow beneficial to patients with bidirectional Glenn?. J Thorac Cardiovasc Surg. 2013; 145: 451-454 Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar ,3 Gray R.G. Altmann K. Mosca R.S. et al. Persistent antegrade pulmonary blood flow post-Glenn does not alter early post-Fontan outcomes in single-ventricle patients. Ann Thorac Surg. 2007; 84: 888-893 Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar However, the oxygen saturation difference between patients with and without APBF at SCPC is typically clinically modest and may become indistinguishable before the Fontan procedure. Data to show that any measured increase in PA size with APBF is sustained after the Fontan procedure or improves Fontan outcomes in the long term are lacking. Moreover, any extended time for somatic growth between SCPC and the Fontan operation in the patients with APBF would a priori allow for PA growth as well. Therefore, the link between preserved APBF at SCPC and durable benefit or sustained improved outcomes is weak on the basis of available information. Influence of Antegrade Pulmonary Blood Flow on Outcomes of Superior Cavopulmonary ConnectionThe Annals of Thoracic SurgeryVol. 114Issue 5PreviewWe 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. Full-Text PDF