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.
Subject(s)
Fontan Procedure , Tetralogy of Fallot/surgery , Ventricular Outflow Obstruction/surgery , Adolescent , Child , Child, Preschool , Echocardiography , Female , Follow-Up Studies , Humans , Infant , Male , Pulmonary Valve/abnormalities , Pulmonary Valve Insufficiency/complications , Pulmonary Valve Stenosis/complications , Pulmonary Valve Stenosis/congenital , Reoperation , Tetralogy of Fallot/complications , Time Factors , Treatment Outcome , Ventricular Outflow Obstruction/complicationsABSTRACT
OBJECTIVE: To determine the efficacy of bidirectional Glenn shunt (BDG) without cardiopulmonary bypass (CPB). STUDY DESIGN: Quasi experimental study. PLACE AND DURATION OF STUDY: The Armed Forces Institute of Cardiology and National Institute of Heart Diseases (AFICNIHD), Rawalpindi. METHODOLOGY: Thirty one patients underwent BDG without CPB between January 2006 to December 2007. Subjects for off pump BDG were those who did not require any intracardiac repair, had good sized branch pulmonary arteries, had acceptable PA pressures (< 16 mm Hg), and did not have any significant atrio-ventricular (AV) valve regurgitation. The off pump BDG was performed using veno-venous shunt between the superior vena cava (SVC) and right atrium (RA) following heparinization. All patients underwent discharge echocardiography to assess BDG patency. Statistical significance was determined using t-test with statistical significance at p < 0.05. RESULTS: There were 18 males and 13 females. All patients survived. Twenty seven (87.09%) patients received BDG and 04 patients (12.90%) received bilateral BDG. Atrial septectomy with inflow occlusion was performed in 5 patients. Antegrade pulmonary blood flow was left in 24 (77.41%) of 31 patients. There was significant improvement in postoperative SpO2 (p = 0.000) in all the cases. There were no postoperative neurologic complications. Sepsis occurred in 2 patients who ultimately recovered. One patient had chylothorax which stopped after three (03) days in ICU. No SVC/PA distortions were noted by discharge echocardiography. Eliminating CPB reduced the cost of the procedure substantially and saved the patients from its inherent complications. CONCLUSION: BDG without CPB is a safe procedure in selected patients. It avoids CPB related problems and is cost effective, with excellent results.