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J Thorac Cardiovasc Surg 1999;118:681-691
© 1999 Mosby, Inc.

SURGERY FOR CONGENITAL HEART DISEASE

BIDIRECTIONAL SUPERIOR CAVOPULMONARY ANASTOMOSIS IMPROVES MECHANICAL EFFICIENCY IN DILATED ATRIOPULMONARY CONNECTIONS

From the Cardiac Dynamics Laboratory,^a Division of Cardiology, Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pa, and the Department of Cardiac Surgery,^b Boston Children’s Hospital, Harvard University, Boston, Mass.

Address for reprints: Albert C. Lardo, PhD, Johns Hopkins University School of Medicine, 4242 JHOC, Baltimore, MD 21287 (E-mail: alardo{at}mri.jhu.edu ).

Objective: Few therapeutic options exist for patients with failing dilated atriopulmonary connections. We addressed the hypothesis that a bidirectional superior cavopulmonary anastomosis will improve the hemodynamic efficiency of dilated atriopulmonary connections while maintaining physiologic pulmonary flow distributions.
Methods: Dilated atriopulmonary connections with and without a bidirectional superior cavopulmonary anastomosis were created in explanted sheep heart preparations and transparent glass models. A mechanical energy balance and flow visualization were performed for 6 flow rates (1-6 L/min), both with and without the bidirectional superior cavopulmonary anastomosis, and were then compared. A novel contrast echocardiographic technique was used to quantify inferior vena cava flow (hepatic venous return) distributions into the pulmonary arteries.
Results: The rate of fluid-energy dissipation was 52% ± 14% greater in the dilated atriopulmonary anastomosis than in the bidirectional superior cavopulmonary anastomosis model over the range of flow rates studied (P = 6.3E^–3). Total venous return passing to the right pulmonary artery increased from 41% ± 2% to 47% ± 3% (P = 9.7E^–3) and that for inferior vena cava flow decreased from and 42% ± 3% to 12% ± 4% (P = 3.3E^–4) after addition of the bidirectional superior cavopulmonary anastomosis. Flow visualization confirmed more ordered atrial flow in the bidirectional cavopulmonary anastomosis model, resulting from a reduction of caval flow stream collision and interaction.
Conclusions: A bidirectional cavopulmonary anastomosis reduces fluid-energy dissipation in atriopulmonary connections, provides a physiologic distribution of total flow, and maintains some hepatic venous flow to each lung. This approach may be a technically simple alternative to atriopulmonary takedown procedures and conversions to total cavopulmonary connections in selected patients.