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J Thorac Cardiovasc Surg 1999;118:368
© 1999 Mosby, Inc.

BRIEF COMMUNICATIONS

Commentary

The report by Jahangiri and associates describes the case histories of 7 patients with simple forms of single ventricle (6 with pulmonary atresia with intact ventricular septum; 1 with tricuspid atresia) who underwent placement of Glenn shunts (1 classic; 6 bidirectional) without the use of either cardiopulmonary bypass (CPB) or some form of decompressing shunt. The authors believe that their patients did not have neurologic complications and therefore suggest that this is a reasonable method for performing the Glenn shunt.

A fundamental problem with this report is that the authors are suggesting a new technique that puts the brain at risk, and yet they have failed to document the safety of the method in adequately protecting the brain. Many similar reports have appeared in the surgical literature regarding techniques such as retrograde cerebral perfusion without careful studies to document safety of the brain. The only statement made by Jahangiri and colleagues is that "no neurologic deficits were detected." In a surgical report, I interpret this statement to mean that the patient was neither comatose nor densely hemiplegic: that is, the patient had not had an "end-of-the-bed stroke." Ideally, these patients should have undergone careful examination both before and after the procedure by a neurologist who might have detected subtle changes in coordination and visual fields, for example, deficits that are unlikely to be noticed by surgeons.

Jahangiri and coworkers made an empiric decision to attempt to maintain the cerebral perfusion pressure, which they define as the difference between the systolic arterial pressure and the mean jugular venous pressure, as high as at least 30 mm Hg. Unfortunately, this is indeed, as the authors state, an entirely "empiric" judgment for which no reference is given. The authors might have considered using new monitoring modalities such as near-infrared spectroscopy or transcranial Doppler assessment of cerebral blood flow velocity to supplement their empiric blood pressure monitoring. However, even these techniques are unproven for monitoring the brain in such circumstances.

Jahangiri and colleagues are not alone in suggesting that various forms of cavopulmonary anastomosis can be performed without CPB. Petrossian and associates ¹ are currently recommending that the extracardiac conduit Fontan procedure be undertaken without CPB with the use of a veno- venous shunt system. They believe that the deleterious effects of CPB justify this approach. Their technique and similar veno-venous shunt procedures proposed by others for the bidirectional Glenn shunt carry the risk that the quality of the cavopulmonary anastomosis may be compromised by this approach. These techniques also may limit cerebral blood flow in children who are already cyanosed. Their use, therefore, could result in a cerebral hypoxic/ischemic injury. It is essential that those proposing such methods work closely with their neurologists to document the absence of even subtle neurologic insults. Ideally, these children should also undergo psychometric or developmental assessment by psychologists, as well as careful intraoperative monitoring of the brain with the most sophisticated methods available.

There is no question that current methods for support of the patient during cardiac surgery, such as CPB, leave much to be desired. Jahangiri and colleagues are to be congratulated for seeking an innovative method for minimizing such injury. I await with interest their careful documentation of the safety for the brain of their intriguing new method of performing the Glenn shunt.

References

1. Petrossian E, Reddy VM, McElhinney DB, Addersdijk GP, Moore P, Parry AJ, et al. Early results of the extracardiac conduit Fontan operations. J Thorac Cardiovasc Surg 1999;117:688-96. [Abstract/Free Full Text]
   

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				S. T. Hussain, A. Bhan, S. Sapra, R. Juneja, S. Das, and S. Sharma The bidirectional cavopulmonary (Glenn) shunt without cardiopulmonary bypass: is it a safe option? Interactive CardioVascular and Thoracic Surgery, February 1, 2007; 6(1): 77 - 82. [Abstract] [Full Text] [PDF]

				J. Liu, Y. Lu, H. Chen, Z. Shi, Z. Su, and W. Ding Bidirectional Glenn procedure without cardiopulmonary bypass Ann. Thorac. Surg., April 1, 2004; 77(4): 1349 - 1352. [Abstract] [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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): Richard A. Jonas Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Jonas, R. A. Search for Related Content PubMed PubMed Citation Articles by Jonas, R. A.