Bidirectional Glenn Anastomosis Research Articles

Norwood Operation with Right Ventricular-Pulmonary Artery Shunt Versus Comprehensive Stage II After Bilateral Pulmonary Artery Banding Palliation.

As a strategy for the primary Norwood operation, the right ventricular-pulmonary artery shunt is associated with satisfactory early outcome. However, use of this shunt after bilateral pulmonary artery banding remains controversial. This study compared the operative outcomes and late hemodynamics in patients who underwent the Norwood operation, preceded by bilateral pulmonary artery banding, with a right ventricular-pulmonary artery shunt or with bidirectional Glenn anastomosis (comprehensive stage II strategy).We retrospectively reviewed 38 patients who underwent the Norwood operation preceded by bilateral pulmonary artery banding between 2004 and 2017. Of these, 17 underwent the Norwood operation with a right ventricular-pulmonary artery shunt (Group S), whereas 21 underwent the comprehensive stage II strategy (Group G).5 years after the Norwood operation, 10 (60%) and 17 (81%) patients in Group S and Group G, respectively, underwent the Fontan procedure. Group S showed significantly lower pressure in the superior vena cava after bidirectional Glenn anastomosis than Group G (13 ± 2 mmHg vs. 18 ± 3 mmHg; p < 0.01), but pressures were similar after the Fontan procedure. The right ventricular end-diastolic volume at 1 year post-Fontan procedure was significantly higher in Group S than in Group G (142 ± 41% vs. 91 ± 28%; p < 0.01).In terms of early outcomes, the Norwood operation with a right ventricular-pulmonary artery shunt enabled low pressure in the superior vena cava, but in the long term, this shunt adversely influenced the right ventricular volume.

P89: Stage II Single Ventricle Patients Can Be Successfully Bridged to Transplant with a Pulsatile Ventricular Assist Device and Bidirectional Glenn Anastomosis

P89: Stage II Single Ventricle Patients Can Be Successfully Bridged to Transplant with a Pulsatile Ventricular Assist Device and Bidirectional Glenn Anastomosis

Determination of Contrast Timing by Time-Resolved Magnetic Resonance Angiography in Patients With Bidirectional Glenn and Hemi-Fontan Anastomoses.

Children with single-ventricle congenital heart disease undergo a series of operations to maintain their pulmonary circulation including bidirectional Glenn (BDG) or hemi-Fontan in the second stage to create a superior cavopulmonary anastomosis. We aimed to optimize cardiovascular angiography protocols by determining optimal contrast timing of pulmonary and systemic circulation on magnetic resonance angiography (MRA) performed with the technique of time-resolved imaging with interleaved stochastic trajectories (TWIST). Cardiac TWIST MRA with lower extremity (LE) contrast injection was analyzed in 92 consecutive patients with a BDG or hemi-Fontan anastomosis. Contrast arrival time to inferior vena cava was set to zero to determine the relative time-to-peak (TTP) of the target vessels. Time-to-peak of each vessel was compared by age (<2 or ≥2 y), ejection fraction (<54% or ≥54%), the median values of heart rate (<111 or ≥111 beats per minute), body surface area (BSA, <0.59 or ≥0.59), cardiac index (<6.04 or ≥6.04), and indexed ascending aorta flow (AscAo_i, <5.3 or ≥5.3). The TTP of the vessels was also correlated with the volumetric parameters. The mean age of 92 patients (32 female, 60 male) was 3.1 years (0.7-5.6 years). With LE injection, the first peak was depicted in AscAo. Time-to-peak of the pulmonary arteries was approximately 9 seconds later than AscAo. The TTP difference between pulmonary arteries and AscAo was shorter in high heart rate group (8.3 vs 10 seconds, P < 0.001). The TTP difference between AscAo and the mean of pulmonary arteries was significantly shorter in high cardiac index group (8.4 vs 9.9 seconds, P < 0.01) and high AscAo_i group (8.7 vs 9.7 seconds, P = 0.03). The TTP differences were not significant by age, ejection fraction, and BSA. Cardiac index and AscAo_i were negatively correlated with all TTPs except AscAo. The ejection fraction, stroke volume, and atrioventricular regurgitation fraction did not correlate with the TTP. In patients with BDG or hemi-Fontan anastomosis, TTP of the pulmonary arteries on TWIST MRA via LE intravenous injection is approximately 9 seconds later than AscAo, approximately 8 and 10 seconds later in high and low heart rate groups, respectively. Cardiac index and AscAo_i have less effect on the TTP than the heart rate. There was no TTP difference of the pulmonary arteries by age, BSA, and ejection fraction and no correlation with ejection fraction, stroke volume, and atrioventricular regurgitation fraction. These data can be used to guide timing of pulmonary arterial enhancement of single-ventricle patients after BDG or hemi-Fontan anastomosis.

Bilateral Bidirectional Glenn Anastomosis in an Adult Patient with Aneurysmal Degeneration after an Original Blalock-Taussig Shunt

Bilateral Bidirectional Glenn Anastomosis in an Adult Patient with Aneurysmal Degeneration after an Original Blalock-Taussig Shunt

Impact of bilateral bidirectional Glenn anastomosis on staged Fontan strategy and Fontan circulation.

The aim of this study was to identify the impact of bilateral bidirectional Glenn (BBDG) anastomosis on staged Fontan strategy and late Fontan circulation. Of 267 patients who underwent bidirectional Glenn prior to Fontan completion between 1989 and 2013, 62 patients (23%) who underwent BBDG were enrolled in this study. Age at operation was 0.84 years (25th-75th percentile: 0.58-1.39). Thirty-three patients had heterotaxy syndrome (53%). The mean follow-up period was 12.7 ± 8.1 (max. 30.6) years. The overall survival rate at 15 years was 73%. Although 49 patients (79.0%) went on to Fontan completion, 12 patients (19.4%) died without achieving it. Thrombus formation and poor development in a central pulmonary artery were not observed, but obstruction of the superior vena cava (SVC) occurred in 8 patients (13%), mainly those with right atrial isomerism (P = 0.037). SVC obstruction was not, however, a risk factor for mortality (P = 0.097) or Fontan completion (P = 0.41). The shape of BBDG anastomosis, symmetricity of pulmonary blood flow, impingement of caval blood flow returning from the superior and inferior vena cavae or coexisting interrupted inferior vena cava with azygos or hemi-azygos continuation did not affect late Fontan outcomes, such as overall survival, freedom from protein-losing enteropathy or pulmonary arterio-venous malformation rates. SVC obstruction after BBDG frequently occurred, mainly in patients with right atrial isomerism; however, its direct impact on prognosis or achieving Fontan completion was not identified. Once Fontan circulation was established, the arrangement of the Fontan pathway did not affect late Fontan outcomes.

The increase of the pulmonary blood flow inhigh-risk hypoxic patients with a bidirectional Glenn anastomosis.

An additional shunt in single ventricle patients with Glenn anastomosis may increase pulmonary flow at the expense of ventricle volume overloading. The performance of the modification depends on pulmonary resistance, indicating better results in favorable hemodynamic conditions. The study aims at analyzing the influence of precisely adjusted pulsatile shunt in borderline high-risk Glenn patients on early and late results. The study involved 99 patients (including 21 children) with the bidirectional Glenn and accessory pulsatile shunt (BDGS group), and 78 patients with the classic bidirectional Glenn anastomosis (BDG group). There was 1 death in the BDGS group and 4 deaths in the BDG group. No difference in mortality (P = 0.71) was found. The Fontan completion was achieved in 69 (88.5%) children in the BDG group and 18 (85.7%) patients in the BDGS group, without fatalities. No intergroup differences in postoperative pulmonary artery pressure (P = 0.10), ventilation time (P = 0.12), the McGoon ratio (P = 0.9), or chylothorax frequency (P = 0.14) were observed. Intensive care unit (P = 0.28) and hospitalization (P = 0.05) times were comparable. Echocardiography revealed no significant differences in the ventricle and atrioventricular valve function between groups. In the BDGS group, higher blood oxygen saturation (P = 0.03) and increase of the McGoon index (P = 0.002) were noted. Bidirectional Glenn anastomosis with precisely adjusted accessory pulmonary blood flow provides stable hemodynamics and adequate oxygen saturation in borderline, profoundly hypoxic patients. An advantageous pulmonary artery development before Fontan completion was observed.

The Effect of Hypoxic Gas Therapy Using Nitrogen Before Bilateral Pulmonary Artery Banding on Hemodynamics and Pulmonary Artery Development

This study aimed to identify its influence on pulmonary development and hemodynamics before bidirectional Glenn (BDG) anastomosis. This retrospective study involved 30 consecutive patients with univentricular hearts who underwent bilateral pulmonary artery banding (bil-PAB) and BDG anastomosis between September 2011 and September 2018 at our institution. These patients were classified into the nitrogen (N = 12) and no nitrogen (N = 18) groups according to their use of hypoxic gas therapy. Clinical echocardiographic, operative, and catheter examination data were reviewed. Nakata index was 131 (110-167) in the nitrogen group and 138 (88.4-161.7) in the no nitrogen group (P = 0.8). Pulmonary vascular resistance (PVR) was 1.50 (1.30-2.4) in the nitrogen group and 138 (88.4-161.7) in the no nitrogen group (P = 0.3). There was no statistical difference between the pulmonary development in both groups. In the subgroup of hypoplastic left heart syndrome patients, there was a statistical difference. RVEDV% of normal was 232.5 (215-239) in the nitrogen group and 201 (161-209) in the no nitrogen group (P = 0.03). Pulmonary development was not significantly different when hypoxic gas therapy was performed using nitrogen vs. not using nitrogen. However, RVEDV% of normal might be larger with hypoxic gas therapy using nitrogen. Although there is no obvious systemic atrioventricular valve regurgitation exacerbation with hypoxic gas therapy, it might be useful to prevent a decrease in PVR and may also affect bil-PAB and subclinical increase in systemic atrioventricular valve regurgitation.

Wada serca typu criss-cross heart współwystępująca z malpozycją wielkich naczyń i dekstrokardią — kompleksowe leczenie złożonej wrodzonej wady układu sercowo-naczyniowego o rzadkiej morfologii

The criss-cross heart congenital defect (CHD) concomitant with transposition of the great arteries has an incidence of less than 0.1% of all inherited heart anatomy abnormalities. It derives from the anomaly of cardiac rotation around its long axis after ventricular septation, and results in an atypical relation between the ventricles and the atria. Furthermore, such patients may also present with ventricular septal defect (VSD), large vessel malposition, double outflow and/or right ventricular hypoplasia (RV), pulmonary artery stenosis (PA), and tricuspid valve hypoplasia. A 7-month-old patient after a transcatheter pulmonary balloon valvuloplasty and a surgical unilateral modified Blalock-Taussig (BT) shunt was admitted to the paediatric cardiac surgery department for further treatment. CHD had been diagnosed prenatally and confirmed after birth. Echocardiographic study revealed dextrocardia and a criss-cross heart pathology with discordant atrioventricular (AV) and ventriculoarterial relations. Intracardiac pathology was concomitant with transposition of the great arteries [aorta originating from the RV, and PA from above the VSD], subvalvular and valvular pulmonary stenosis (gradient RV/PA approx. 90 mm Hg), and unobstructed BT shunt. Systemic cyanosis was not observed, and the child’s mental and physical development was undisturbed. After diagnostic catheterisation, the patient was referred for further surgery. Using extracorporeal circulation, a bidirectional Glenn anastomosis was performed, and the BT shunt as well as the PA were closed and dissected. The postoperative course was uncomplicated. More than 90% of criss-cross heart co-occur with levocardia and the concomitance with the AV-related transposition of the great arteries and dextrocardia, to the best of our knowledge, is the second described report in the literature. Thus, the diagnosis of a rare congenital heart defect should be always considered, especially in prenatal diagnostics, and precisely defined during qualification for further surgical treatment.

15O-water PET for evaluation of cardiopulmonary perfusion in complex cyanotic heart disease

BackgroundDynamic 15O-water PET may provide information about cardiopulmonary circulation complementary to MRI and CT in complex cyanotic heart disease.Case presentationWe present a case in which a 15O-water PET scan was used for the first time to map the complex circulation in a univentricular heart patient with dual pulmonary blood supply. The pulmonary blood supply consisted of partially oxygenated blood led from the univentricle to the lungs by the pulmonary artery, plus of venous blood from the upper body lead by a bidirectional Glenn anastomosis to the right pulmonary artery. Despite the bidirectional Glenn anastomosis, the patient developed increasing cyanosis and was considered for heart transplantation. Pulmonary perfusion measurements using MRI were inconclusive due to metal artifacts, and the patient was referred for a 15O-water PET scan. The scan showed significant venovenous collaterals bypassing the lungs. Only the left upper lung lobe was properly perfused. The mean transit time from the superior vena cava to the left ventricle was approximately four times longer than would be expected from a healthy person.ConclusionThe case illustrates that 15O-water PET can complement CT and MRI for quantitative characterization of cardiopulmonary circulation in complex cyanotic heart disease.

Serial changes of tricuspid regurgitation after anatomic repair for congenitally corrected transposition.

The aim of this study was to reveal the serial changes in tricuspid regurgitation (TR) after anatomic repair for congenitally corrected transposition of great arteries. Between 1995 and 2018, 48 patients underwent anatomic repair (atrial/arterial switch in 14 patients, atrial switch and Rastelli in 34 patients). The mean age and weight of the patients during anatomic repair was 33 (interquartile range 21.8-62.1) months and 12 (10.3-16.3) kg. The preoperative TR was less than mild in 15 patients (31.3%), mild-to-moderate in 29 patients (60.4%) and more-than-moderate in 4 patients (8.3%). Ebsteinoid dysplasia of the tricuspid valve (TV) was observed in 7 patients (14.6%). During the study period, no patient underwent TV surgery or bidirectional Glenn anastomosis at the time of anatomic repair. There was 1 in-hospital death and 1 late death. The follow-up was completed by other surviving patients, with a median follow-up period of 12.1 years (5.9-18.1). The overall survival, reoperation-free survival and freedom from permanent pacemaker implantation rate at 15 years were 94.3%, 74.3% and 81.5%, respectively. The mean TR grade was 2.0 (1.0-2.6) preoperatively, 2.0 (1.0-2.0) at 1 year, 2.0 (2.0-2.0) at 5 years and 2.0 (2.0-2.0) at 10 years after anatomic repair. A Cox proportional hazards model showed that association of Ebsteinoid dysplasia of the TV, type of anatomic repair and previous pulmonary artery banding did not affect freedom from death or the more-than-moderate TR rate. There were 2 patients who underwent TV surgery after the anatomic repair for severe TR; TV repair was successfully done for 1 patient, the other required semi-closure of TV and one and one-half ventricle conversion. TR remained subclinical or improved in the majority of patients after anatomic repair without TV repair. However, there were a few patients whose TR progressed to severe or massive, then required TV surgery after anatomic repair. Although exposure was difficult, TR was sometimes repairable following atrial switch, otherwise, one and one-half ventricle repair conversion would be the choice of treatment.

An Analysis of Hospital Mortality After Cardiac Operations in Children With Down Syndrome

Children with Down syndrome (DS) have lower mortality compared to nonsyndromic (NS) children after atrioventricular septal defect (AVSD) repair. Limited data exist regarding hospital mortality and utilization after other congenital heart disease (CHD) operations in DS. We compared hospital mortality and utilization after CHD operations in both populations and hypothesized that the survival benefit in children with DS is not consistent across CHD lesions. The Texas Inpatient Public Use Datafile was queried for all patients <18 years old undergoing operations for CHD between 1999 and 2016. Hospital mortality, length-of-stay and charges were compared between DS and NS groups, stratified by CHD operation using mixed-effects multivariable analyses and propensity score matching analyses adjusting for prematurity, low birth weight, age, and sex. Over the 18-year period, 2841 cases with DS underwent CHD operations compared to 25,063 NS cases. The most common types of interventions performed in DS were AVSD repair, isolated ventricular septal defect (VSD) repair and tetralogy of Fallot (TOF) repair. By multivariable analyses, DS was associated with lower mortality after isolated AVSD repair (RR 0.40 [IQR 0.20-0.79]), and higher hospital mortality after bidirectional Glenn anastomosis (BDG) (RR 5.17 [IQR 2.10-12.77]) and TOF/pulmonary atresia repair (RR 9.71 [IQR 2.16-43.68]) compared to NS children. Similar results were noted using propensity score matching. Children with DS had lower mortality after AVSD repair than NS children, but higher mortality after operations for BDG and TOF/pulmonary atresia. Further study is needed to determine if the presence of pulmonary hypertension in DS modifies the association between DS and mortality depending on cardiac lesion.

Improved Outcomes in Management of Hypoplastic Left Heart Syndrome Associated With Congenital Diaphragmatic Hernia: an Algorithmic Approach

Hypoplastic left heart syndrome (HLHS) is the second most common congenital heart disease associated with congenital diaphragmatic hernia (CDH). The reported survival rate of neonates with CDH and HLHS is only 1%-5%. We review our experience with CDH and HLHS and compare our outcomes with published literature. Retrospective review of all neonates with CDH and HLHS at our institution over a 10-year period was performed. The morphology of cardiac and diaphragm defects, clinical course, treatment strategies, and outcomes were reviewed, and an algorithmic approach was proposed. Five patients with CDH and HLHS were treated between 2006 and 2016. All had mitral stenosis with aortic stenosis. Four patients had a left-sided Bochdalek diaphragmatic hernia and 1 patient had a large bilateral Morgagni hernia. Two (2/4) of the Bochdalek hernias were associated with significant pulmonary hypoplasia and required patch closure of the CDH; both were palliated with percutaneous ductal stents and both died. Three patients underwent primary Norwood operation followed by repair of less severe CDH defect. All 3 patients are currently well and have survived bidirectional Glenn anastomosis; one patient is well after Fontan operation. Successful palliation of neonates with HLHS and associated CDH is possible in the current era. Outcome is determined primarily by the severity of the CDH and the degree of associated pulmonary hypoplasia. An algorithmic team approach is helpful in management of this difficult group of patients.

Cardiovascular anatomy in children with bidirectional Glenn anastomosis, regarding the transcatheter Fontan completion

Transcatheter stent-secured completion of total cavopulmonary connection (TCPC) after surgical preparations during the Glenn anastomosis procedure has been reported, but complications from this approach have precluded its clinical acceptance. To analyse cardiovascular morphology and dimensions in children with bidirectional Glenn anastomosis, regarding the optimal device design for transcatheter Fontan completion without special surgical "preconditionings". We retrospectively analysed 60thoracic computed tomography and magnetic resonance angiograms performed in patients with a median age of 4.1years (range: 1.8-17.1years). Additionally, we simulated TCPC completion using different intra-atrial stent-grafts in a three-dimensional model of the representative anatomy, and performed calculations to determine the optimal stent-graft dimensions, using measured distances. Two types of cardiovascular arrangement were identified: left atrium interposing between the right pulmonary artery (RPA) and inferior vena cava, with the right upper pulmonary vein (RUPV) orifice close to the intercaval axis (65%); and intercaval axis traversing only the right(-sided) atrial cavity, with the RUPV located posterior to the atrial wall (35%). In the total population, the shortest median RPA-to-atrial wall distance was 1.9mm (range: 0.6-13.8mm), while the mean intra-atrial distance along the intercaval axis was 50.1±11.2mm. Regardless of the arrangement, 83% of all patients required a deviation of at least 5.9±2.4mm (range: 1.2-12.7mm) of the stent-graft centre at the RUPV level anteriorly to the intercaval axis to avoid covering or compressing this vein. Fixing the anterior deviation of the curved stent-graft centre at 10mm significantly decreased the range of bend angle per every given RUPV-RPA distance. For both types of cardiovascular arrangement, after conventional bidirectional Glenn anastomosis, the intra-atrial curved stent-graft seemed most suitable for achieving uncomplicated TCPC completion percutaneously without previous surgical "preconditionings" in the majority of children. Experimental study is necessary to validate this conclusion.

Vascular anatomy in children with univentricular hearts regarding transcatheter bidirectional Glenn anastomosis

Transcatheter stent-secured Glenn anastomosis, aiming to reduce the invasiveness of palliation in patients with univentricular heart defects, has been reported in large experimental animals. The advent of biodegradable stents and tissue-engineered vascular grafts will make this procedure a reality in human patients. However, the relationship between the superior vena cava (SVC) and the right pulmonary artery (RPA) is different in humans. To characterise vascular anatomy in children with univentricular hearts, regarding technical aspects and device design for this procedure. Retrospective analysis of 35 thoracic computed tomography angiograms at a mean age of 18.1±22.4 months. Two types of arrangement between the SVC and the RPA were identified: anatomy convenient for immediate wire passage and stent deployment between the two vessels (60%); and pattern of early RPA branching, requiring the perforation wire to traverse the intervascular space to avoid entrance into the upper RPA branch (40%). In patients with the convenient vascular arrangement, the vessels were nearly perpendicular, having immediate contact, with the posterior SVC aspect partially "wrapping" the adjacent RPA in most patients. In patients with early RPA branching, the mean shortest SVC-to-central RPA distance was 4.3±2.7mm. For the total population, the mean length of proximal SVC that allowed stent deployment without covering the brachiocephalic vein was 15.6±5.1mm. A trumpet-shaped covered stent in a craniocaudal orientation reaching from the SVC into the prebranching RPA seems most suitable for achieving bidirectional Glenn anastomosis percutaneously in humans. However, the short length of the proximal SVC and the presence of early RPA branching pose challenges for optimal design of the dedicated device.

Use of a Three Dimensional Printed Cardiac Model to Assess Suitability for Biventricular Repair.

Three dimensional (3D) printing is rapidly gaining interest in the medical field for use in presurgical planning. We present the case of a seven-year-old boy with double outlet right ventricle who underwent a bidirectional Glenn anastomosis. We used a 3D cardiac model to assess his suitability for a biventricular repair. He underwent a left ventricle-to-aorta baffle with a right ventricle-to-pulmonary artery conduit placement. He did well postoperatively and was discharged home with no evidence of baffle obstruction and good biventricular function. A 3D printed model can provide invaluable intracardiac spatial information in these complex patients.

Long-term Results after Bidirectional Glenn Anastomosis in Patients with Hypoplastic Right Heart Syndrome: A Ten-year Single Center Experience

Long-term Results after Bidirectional Glenn Anastomosis in Patients with Hypoplastic Right Heart Syndrome: A Ten-year Single Center Experience

The long-term impact of various techniques for tricuspid repair in Ebstein's anomaly

ObjectiveWe describe a repertoire of repair techniques according to type of Ebstein's anomaly to correct tricuspid valve (TV) incompetence, and report long-term ventricular function and functional outcomes. MethodsSixty-eight patients (mean age, 26.9 ± 7.3 years) with Ebstein's anomaly (type A, n = 21; type B, n = 23; type C, n = 15; type D, n = 9) underwent correction of TV incompetence under normothermic cardiopulmonary bypass. The atrialized ventricle, TV, and subvalvar apparatus were inspected to analyze the precise morphology and determine which leaflet was the most mobile. Various repair strategies (anterior and/or posterior annulorrhapy, Sebening stitich, double-orifice valve technique, with bidirectional Glenn anastomosis if necessary) were used according to the presenting morphology and applied according to the type of Ebstein's anomaly. In all, the atrialized right ventricle (RV) was incorporated into the contractile RV by partial closure of the natural annulus using the most mobile leaflet for valve competence. ResultsThe mean duration of follow-up was 13.25 ± 1.3 years (median, 9.34 years; range, 1-24 years). The mean New York Heart Association class improved from 3.4 to 1.3 (P < .001). The mean severity of TV incompetence was reduced from 3.2 to 1.3 (P < .001). Exercise tolerance tests demonstrated improved maximal oxygen uptake from a mean of 15 ± 7.8 ng/kg/min preoperatively to a mean of 24.9 ± 2.0 ng/kg/min postoperatively (P < .02). Displacement tissue Doppler imaging was used to evaluate overall cardiac performance of the RV and left ventricle and interventricular septum. The mean basal, middle, and apical ventricular strain improved significantly from preoperative values of 18.08%, 15.6%, and 13.9%, respectively to postoperative values of 25.7% (P < .011), 23.7% (P < .001), and 19.36% (P < .05), respectively. Freedom from reoperation was 100% at 1 year, 98.3% at 5 years, and 92.9% at 20 years. Early mortality was 2.9%, and late mortality was 5.8%. The overall survival rate was 97.6% at 30 days, 92.7% at 5 years, and 91.26% at 20 years. ConclusionsThe various repair techniques, all of which preserve the atrialized chamber and are used individually according to morphology, provide satisfactory long-term ventricular function and functional outcome even in severe types of Ebstein's anomaly.

Ring-Reinforced Sano Conduit at Norwood Stage I Reduces Proximal Conduit Obstruction

Reinterventions for proximal conduit obstruction or on the pulmonary arteries are frequent after the Sano-modified stage I Norwood palliation of hypoplastic left heart syndrome. We report our initial experience with a modified Sano technique using a ring-reinforced graft inserted transmurally through the right ventricle with a limited ventriculotomy. All patients who underwent the Sano-modified stage I Norwood procedure using a modified "dunked" technique from September 2010 to September 2012 at our institution were reviewed. An historical control group consisted of patients undergoing the traditional Sano right ventricle-to-pulmonary artery conduit anastomosed to the epicardium. The primary outcome measures included death, reintervention on the Sano and pulmonary arteries, and ventricular function. The study included 29 patients. No patients required intervention on the Sano conduit, pulmonary arteries, or aortic arch before discharge after the stage I procedure. During a median follow-up of 20 months (range, 26 days to 3.3 years), survival was estimated at 96.6% ± 3.4% at 1 month and 86.2% ± 6.4% at the latest follow-up. One patient underwent heart transplantation. No interstage intervention was required on the proximal or distal Sano conduit. Intervention was required on the midportion of the conduit in 1 patient and on the pulmonary arteries in 3 patients. At the time of the bidirectional Glenn anastomosis, freedom from conduit and pulmonary artery intervention was estimated at 92.3% ± 7.4% and 90.1% ± 8.7%, respectively, and global right ventricular dysfunction was mild or less in 84% (16 of 19) of patients. The ring-reinforced right ventricle-to-pulmonary artery Sano conduit transmurally inserted into the right ventricle provides acceptable results, with a low incidence of interstage reinterventions in patients undergoing stage I palliation.

Feasibility of routine cardiac MRI in selected patients before bidirectional Glenn Anastomosis. A retrospective single center study

Feasibility of routine cardiac MRI in selected patients before bidirectional Glenn Anastomosis. A retrospective single center study

Evaluation of bilateral pulmonary artery banding for initial palliation in single-ventricle neonates and infants: risk factors for mortality before the bidirectional Glenn procedure.

Bilateral pulmonary artery banding is considered as 'first-stage' palliation for neonates who have hypoplastic left heart syndrome. This study aimed to identify risk factors that influence outcome before the bidirectional Glenn operation. This retrospective evaluation involved 30 consecutive patients with hypoplastic left heart syndrome, or a variant, who underwent bilateral pulmonary artery banding between August 2005 and December 2011 at our institution. Clinical echocardiographic, operative and catheter examination data were reviewed. This study included 9 patients with hypoplastic left heart syndrome and 21 patients with variants. Bilateral pulmonary artery banding was performed at a median age of 7 days. Finally, 19 patients had the bidirectional Glenn operation performed (Group A), and the remaining 11 patients died before the bidirectional Glenn procedure (Group NA). Catheter evaluations before the bidirectional Glenn procedure were carried out at 97 ± 34 days. The mean pulmonary venous wedge pressure was significantly lower (Group A: 13.1 ± 3.1 mmHg vs Group NA: 22.9 ± 3.7 mmHg, P <0.01), systemic ventricular ejection fraction was higher (54.4 ± 10.7 vs 41.7 ± 9.9%, P <0.05), systemic ventricular end-diastolic pressure was lower (6.1 ± 2.4 vs 10.5 ± 3.6 mmHg, P <0.05) and the rate of patients with more than mild systemic atrioventricular valve regurgitation was lower in Group A than in Group NA (15.7 vs 62.5%, P <0.05). Multivariate logistic regression analysis showed that mean pulmonary venous wedge pressure was the most significant predictor of attaining the bidirectional Glenn anastomosis (odds ratio: 2.35, P <0.01). Postoperative atrioventricular valve regurgitation, cardiac function and mean pulmonary venous wedge pressure are closely correlated with mortality after bilateral pulmonary artery banding. Additional treatments, including operations, are considered to maintain cardiac function and not to raise pulmonary venous wedge pressure before the bidirectional Glenn procedure.