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Ann Thorac Surg 2003;76:1917-1921
© 2003 The Society of Thoracic Surgeons

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Original article: cardiovascular

Effects of controlled antegrade pulmonary blood flow on cardiac function after bidirectional cavopulmonary anastomosis

^a Division of Cardiothoracic Surgery, Louisiana State University, and Children's Hospital, New Orleans, Louisiana, USA
^b Division of Pediatric Cardiology, Louisiana State University, and Children's Hospital, New Orleans, Louisiana, USA

Accepted for publication June 30, 2003.

^* Address reprint requests to Dr Caspi, Children's Hospital, 200 Henry Clay Ave, New Orleans, LA 70118, USA.
e-mail: caspij{at}aol.com

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
BACKGROUND: Bidirectional cavopulmonary anastomosis (BCPA) has been used as an intermediate stage in the treatment of patients with single-ventricle physiology. Leaving additional antegrade pulmonary blood flow has been shown to improve postoperative arterial blood oxygen saturations; however, controversy continues over whether the potential increase in systemic venous pressure is detrimental. We studied the effects of controlled antegrade pulmonary blood flow on cardiac function in patients after BCPA.

METHODS: From January 1993 to July 2000, 128 patients underwent BCPA. Mean age at operation was 6.2 ± 4 months (range 2 to 36 months). In group 1 (n = 72), restricted antegrade pulmonary blood flow was maintained through a native narrowed pulmonary valve or by adjustment of previously placed pulmonary artery band with the goal of maintaining the mean pulmonary artery pressure less than 16 mm Hg. In group 2 (n = 56), BCPA was the only source of pulmonary blood flow.

RESULTS: One hospital death (0.8%) occurred. The mean pulmonary artery pressure at the end of the operation was 13 ± 2 mm Hg in group 1 compared with 12 ± 2 mm Hg in group 2, a difference that was not significant. Patients in group 1 had higher arterial oxygen saturations (84% ± 3% compared with 74% ± 3% in group 2, p < 0.05), and shorter mean hospital stay (9 ± 3 days compared with 15 ± 2 days, p < 0.05). Persistent pleural effusion (> 10 days) or late chylothorax occurred in 4 patients from group 1 and 3 from group 2, a difference that was not significant. During a mean follow-up of 36 ± 10 months no late deaths occurred. The mean oxygen saturation remained higher in group 1, 80% ± 3% compared with 74% ± 4% in group 2, and the hematocrit was lower, at 38% ± 3% compared with 46% ± 4% (p < 0.05 for both comparisons). Cardiac catheterizations were performed in 68 patients before completion Fontan. Total pulmonary artery (Nakata) index was 263 ± 34 mm²/m² in group 1 (n = 40) and 188 ± 13 mm²/m² in group 2 (n = 28) (p < 0.05). The mean pulmonary artery pressure and mean ventricular end-diastolic pressure were similar.

CONCLUSIONS: Controlled antegrade pulmonary blood flow may have favorable effects on cardiac function for a selected group of patients and does not appear to have adverse effects on subsequent suitability for completion Fontan.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
The bidirectional cavopulmonary anastomosis (BCPA) has become a mainstay palliative procedure in the current staged surgical approach for patients with heart disease who are considered candidates for Fontan repair [1, 2]. The main physiologic advantages are an increase of effective pulmonary blood flow without an increase in volume load, less pulmonary artery distortion, and prevention of pulmonary hypertension. Controversy still exists regarding the usefulness of leaving additional antegrade pulmonary blood flow and the potential growth of the pulmonary arteries after creation of the BCPA [3–5]. The arguments for leaving an accessory source of pulsatile pulmonary blood flow through a stenosed pulmonary valve or systemic-pulmonary shunt include possible improvement in postoperative arterial oxygen saturation, promotion of the growth of the pulmonary arteries, and possible prevention of long-term development of pulmonary arteriovenous malformations (PAVMs) [5–7]. However, the antegrade pulmonary flow may also elevate the systemic venous pressure resulting in an increased volume overload on the single ventricle and a higher incidence of persistent pleural effusions [8].

To lessen the adverse effects of persistent elevated pulmonary artery pressure in patients with antegrade pulmonary blood flow, we have modified our surgical technique by applying an adjustable pulmonary artery band and simultaneously measuring the pulmonary artery pressure. Here we report the short- and long-term effects of maintaining controlled antegrade pulmonary blood flow in patients with single-ventricle physiology as evidenced by our experience with this technique.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
We retrospectively reviewed the clinical and surgical records of 128 patients who underwent BCPA from January 1993 to July 2000. Patients were divided into two groups. In group 1 (n = 72 patients) an antegrade pulmonary blood flow through a native stenosed pulmonary valve (n = 30) or a previously banded pulmonary artery (n = 42) was left at the time of BCPA. In group 2 (n = 56 patients) BCPA was the only source of pulmonary blood flow. The mean age at the time of BCPA was 6.2 ± 5 months (range 2 to 36 months) in group 1 and 5.7 ± 4 months (range 3 to 32 months) in group 2. The mean weight was 6.2 ± 2.5 kg (range 4 to 18 kg) in group 1 and 5 ± 3 kg (range 3.8 to 14 kg) in group 2. Table 1 shows the anatomic lesions. Bidirectional cavopulmonary anastomosis was the first surgical procedure in 18 patients; in 110 patients a total of 121 previous palliative surgical procedures were performed (Table 2). Mean preoperative systemic arterial saturation in group 1 was 73% ± 6% (range 65% to 85%) and in group 2 was 75% ± 4% (range 65% to 82%) (NS).

Surgical technique
All operations were performed through a median sternotomy approach using cardiopulmonary bypass with normothermic beating heart (n = 110) or with the aid of a superior vena cava to right atrial shunt (n = 18). A short period of moderate hypothermia (28°C) with blood cardioplegic arrest was used in patients who required additional procedures. The superior vena cava was anastomosed in an end-to-side fashion to the right pulmonary artery using standard techniques. In 10 patients, a persistent left superior vena cava was anastomosed to the left pulmonary artery in the same fashion. Associated surgical procedures were performed in 22 patients: atrial septectomy (n = 4), Damus-Stansel-Kaye procedure (n = 5), Tricuspid valvuloplasty (n = 4), and pulmonary arterioplasty (n = 9). After completion of the BCPA, a 2-0 Prolene suture (Ethicon, Somerville, NJ) was placed around the main pulmonary artery and passed through a snare of 8F polyethylene tube.

After weaning the patient from cardiopulmonary bypass the pressure was measured directly in the pulmonary artery, or after introducing a 3F catheter (Medtronic, Minneapolis, MN) in the superior vena cava at the cannulation site. All pressure measurements were performed at normothermia with the patient in sinus rhythm and on 50% inspired oxygen. The band was tightened to achieve a mean pulmonary pressure of less than 16 mm Hg. The tightness of the band was maintained by applying several surgical hemo clips to the polyethylene tube at the proximal end, which was placed under the xiphoid.

All patients were mildly sedated in the intensive care unit after surgery. Pulmonary artery pressure, right atrial pressure, and systemic arterial pressure were monitored continuously. Pulmonary artery catheters were removed before chest closure or within 24 hours after surgery without any complications.

Statistical analysis
Preoperative and postoperative data were analyzed and compared between groups. Data are expressed as mean ± SD. A two-tailed Mann-Whitney U test was used to compare variables between groups and ² test was used to compare the frequency of postoperative complications using SPSS for Windows (SPSS Inc, Chicago, IL). The difference was considered statistically significant when the p value was 0.05 or less.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
Table 3 shows the postoperative and hemodynamic data after BCPA in patients with and without antegrade pulmonary blood flow. The mean pulmonary artery and atrial filling pressures were comparable between the groups. After extubation the arterial oxygen saturation on room air was significantly higher in group 1 (p < 0.05). Inotropic support with dopamine (> 3 µg · kg^-1 · min^-1) for more than 48 hours was required for 10 patients in group 1 and 28 patients in group 2 (p < 0.05). Duration of mechanical ventilation and stay in the intensive care unit were significantly shorter in group 1 (p < 0.05). The incidence of transient supraventricular tachyarrhythmias was similar in both groups. Oxygen saturations at the time of discharge were significantly higher (p < 0.05) in group 1 (82% ± 2%) compared with group 2 (72% ± 3%).

Early reoperation was required in 2 patients in group 1 because of persistent chylothorax related to excessive pulmonary blood flow. In both cases, cardiac catheterization showed higher pulmonary artery pressure compared with the immediate post-BCPA pressure measurements. Tightening of the pulmonary artery band through a subxiphoid approach was performed 1 and 3 months after the original operations with no further complications. All other patients who had persistent chylous effusion responded favorably to conservative treatment consisting of chest tube drainage and fat-free diet.

There was one hospital death (0.8%) 26 days after the operation due to sepsis and multiorgan failure in a 10-month-old patient with unbalanced atrioventricular canal, no antegrade pulmonary blood flow, and recurrent pulmonary vein stenosis. During a mean follow-up of 36 ± 10 months (range 6 to 60 months) no late deaths occurred. The oxygen saturations remained higher in group 1 than in group 2 (80% ± 3% compared with 72% ± 4%, p < 0.05), and hematocrits remained lower (38% ± 3% compared with 46% ± 4%, p < 0.05). Cardiac function was assessed by serial echocardiographic studies every 3 to 6 months. Fractional shortening of the ventricle obtained from the most recent M-mode echocardiogram was comparable in both groups (36% ± 3% in group 1 vs 35% ± 3% in group 2) (NS). Sixty-eight patients underwent cardiac catheterizations before completion Fontan (group 1 [n = 40], group 2 [n = 28]). The mean pulmonary artery pressure was 13 ± 2 mm Hg in group 1 and 11 ± 3 mm Hg in group 2 (NS). The ventricular end-diastolic pressure was similar in both groups (7 ± 2 mm Hg in group 1 and 8 ± 2 mm Hg in group 2). The total pulmonary artery (Nakata) index was significantly higher in group 1 than in group 2 (263 ± 34 mm²/m² compared with 188 ± 13 mm²/m²), p < 0.05. No angiographic evidence of pulmonary arteriovenous malformations was obtained. In 2 patients without antegrade pulmonary blood flow, venovenous collaterals developed between the superior and inferior vena cava veins resulting in worsening cyanosis. Coil embolization procedures were performed 8 and 14 months after BCPA.

At the time of Fontan operation an extracardiac conduit with a Gore-Tex (W.L. Gore and Assoc, Flagstaff, AZ) tube (18 to 22 mm) was performed in 48 patients and creation of a lateral tunnel in 20 patients with no operative deaths. The time between BCPA and completion Fontan was slightly longer for patients with antegrade pulmonary blood flow than for patients without antegrade blood flow (24 ± 7 months in group 1 versus 19 ± 4 in group 2, p = 0.07). The antegrade pulmonary blood flow was excluded at the time of completion Fontan by simple ligation of the main pulmonary artery. A regimen of aspirin and low-dose Coumadin was started soon after surgery in all patients.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
Bidirectional cavopulmonary anastomosis has become the intermediate palliative therapy for patients with single-ventricle variants who are candidates for subsequent Fontan operation [1–3]. The results of this analysis support the creation of BCPA with maintenance of controlled antegrade blood flow in patients for whom this anatomy is favorable. Analyses of the clinical sequelae of leaving antegrade pulmonary blood flow have produced conflicting results. Previous studies [7, 9, 10] showed that patients with antegrade pulmonary blood flow had postoperative increases in oxygen saturation and lower hospital mortality rates compared with patients in whom BCPA was the only source of pulmonary blood flow. The present experience supports these findings, in terms of higher oxygen saturation. In contrast, two other reports emphasized the importance of excluding all alternative sources of pulmonary blood flow, arguing that leaving a source of antegrade pulmonary blood flow may lead to the development of superior vena cava syndrome and chronic pleural effusions [11, 12].

Higher operative morbidity has been reported among patients with antegrade pulmonary blood flow in the form of increased incidence of prolonged pleural effusions and longer hospital stay [8, 13, 14]. Again, this study failed to confirm this finding, because the incidence of complications after the approach we adopted was small and equal in both groups. Finally, another reported finding has been an increased early and late operative mortality in patients with antegrade pulmonary blood flow attributed to a higher incidence of early reoperations for adjustment of the pulmonary blood flow [9, 13]. With the technique used in this study to control antegrade pulmonary blood flow, our data showed an increase in postoperative arterial oxygen saturation in patients with antegrade pulmonary blood flow without an increase in early or late operative mortality. Using the technique of intraoperative measurement and the cutoff of less than 16 mm Hg mean pressure, only 2 patients in the series required readjustment of the pulmonary artery band due to excessive blood flow after surgery.

It is important to note that in the present study, the pulmonary trunk was the only source of antegrade blood flow. Although other studies [9, 13] reported leaving an old Blalock-Taussig shunt or adding a new systemic pulmonary shunt at the time of BCPA, we strongly believe that antegrade pulmonary blood flow would better promote the development of the branch pulmonary arteries. In this series we were diligent to remove all previously placed systemic pulmonary shunts because of the potential for distortion of the pulmonary artery with time. The BCPA was performed by incorporating the old systemic-pulmonary anastomotic site into the new cavopulmonary shunt. None of the patients who underwent subsequent cardiac catheterization demonstrated any distortion of the branch pulmonary arteries after pulmonary artery banding.

Reduction of arterial oxygen saturations occurred with time in this series, and was attributed to the discrepancy between the somatic growth of the patients and to the fixed diameter of the pulmonary artery resulting in a gradual diminishment of the antegrade pulmonary blood flow. In fact, we found complete obliteration of the antegrade pulmonary blood flow in 6 patients in this series before completion Fontan.

Although our decision whether to leave antegrade flow was based on intraoperative pressure measurements and was considered favorably when the pulmonary artery pressure was lower than 16 mm Hg, it is possible that continuous monitoring of the pulmonary artery pressure in the intensive care unit during the first 24 to 48 hours after surgery might in fact be a more reliable method to make these pressure measurements. For example, the 2 patients in this study who required late readjustment of the band despite initially low pulmonary artery pressures might have had their elevated pulmonary artery pressure detected earlier if a pulmonary artery line was in place in the postoperative period, similar to what Albanese and colleagues [15] reported. Using a different criterion, Chang and colleagues [12] based their decision to leave antegrade pulmonary blood flow when arterial blood saturation was lower than 70%. However, our experience showed that immediate postoperative arterial blood saturations did not correlate with the development of pleural effusions, and in many patients blood saturations improved with time even in the absence of antegrade pulmonary blood flow.

The potential for growth of the pulmonary arteries after BCPA still remains controversial. In a previous study, Mendelsohn and colleagues [4] questioned the adequacy of pulmonary artery growth after BCPA, whereas Reddy and associates [16] demonstrated that pulmonary artery growth was not reduced after BCPA. Our data clearly showed a significant increase in the size of the pulmonary arteries in patients with antegrade blood flow, based on angiographic indexes obtained before and after surgery, without adverse increase in the pulmonary artery pressure or pulmonary vascular resistance. We speculate that the pulsatile flow may promote development of the pulmonary arteries especially when they are small.

The exclusion of all other sources of pulmonary blood flow at the time of BCPA is aimed to volume unload the single ventricle, improve function of the ventricle, and reduce the degree of atrioventricular regurgitation [12]. In long-term follow-up of these patients we found that leaving a controlled source of antegrade pulmonary blood flow had no adverse effects on late ventricular function or atrioventricular valve regurgitation. Ventricular function and atrioventricular valve competence were comparable in patients after BCPA with and without antegrade blood flow. Similarly, Kobayashi and colleagues [17] showed improved atriventricular valve function associated with reduction in ventricular size. These findings support our assumption that a controlled source of antegrade pulmonary flow has no detrimental effects in terms of subsequent suitability for Fontan procedure. Although division of the pulmonary artery and oversewing of the stump is recommended, we have not seen any residual antegrade blood flow through the pulmonary artery or thrombus formation after simple ligation of the main pulmonary artery.

The development of PAVMs has been described as a late complication of the standard Glenn shunt. Several reports have suggested that leaving a pulsatile blood flow in the pulmonary arteries after BCPA may play an important role in preventing the late development of PAVMs [17, 18]. Other studies have emphasized the importance of the "hepatic factor" carried with the hepatic venous return to the lungs in promoting the growth of the pulmonary arteries and reducing the vascular resistance [19]. Similarly, we have not seen any late development of PAVMs in this series of patients during the entire follow-up period.

We conclude that leaving controlled antegrade pulmonary blood flow has beneficial effects for a selected group of patients after BCPA, and does not add any major risk at time of completion Fontan.

	References

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This Article Abstract Full Text (PDF) Online Discussion Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Joseph Caspi Timothy W. Pettitt T. Bruce Ferguson, Jr Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Caspi, J. Articles by Sandhu, S. K. Search for Related Content PubMed PubMed Citation Articles by Caspi, J. Articles by Sandhu, S. K. Related Collections Congenital - cyanotic