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J Thorac Cardiovasc Surg 2000;119:634-635
© 2000 Mosby, Inc.

LETTERS TO THE EDITOR

Should the bidirectional Glenn procedure be better performed through the support of cardiopulmonary bypass?

Division of Cardiovascular Surgery, Children’s Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, Ontario, K1H 8L1, Canada

To the Editor:

We read with great interest the report of Jahangiri and associates ¹ and the commentary by Jonas on the technique of bidirectional Glenn shunt through a thoracotomy without the use of cardiopulmonary bypass (CPB). We agree that clamping the superior vena cava (SVC) without decompressing the internal jugular system exposes the brain to the effects of reduced cerebral perfusion pressure. We have used electrophysiological indices of cerebral function (electroencephalography or evoked potentials) and transcranial Doppler during bidirectional Glenn shunts in patients with pulmonary atresia without support (n = 2) or through the use of CPB (n = 4). During clamping of the SVC without CPB, major reductions (>50%) in the diastolic, mean, and peak systolic blood flow velocities of the middle cerebral artery were identified, which were followed by mild electrocortical alterations as indicated by longer latencies of the cortically generated evoked potentials. ² In contrast, this situation did not occur or was minimal in those cases in which clamping of the SVC was done with the support of CPB. We have learned that Doppler flow changes and electrocortical alterations may be expected as a result of acute SVC hypertension if the internal jugular venous system is not decompressed. ³ In one of our cases without CPB, an intraoperative shunt into the SVC was indicated due to the presence of extremely low flow velocities and electrocortical alterations during SVC clamping. In this case, while the SVC shunt was patent, flow velocities were maintained and the latencies of evoked potentials returned to preclamping levels. ⁴ In our institution, we routinely use CPB and intraoperative brain function monitoring by transcranial Doppler, near-infrared spectrophotometry, and electroencephalography for children undergoing these procedures. ³ A note of caution should be made that the reported absence of gross neurologic deficits in Jahangiri and colleagues’ cases is not an indicator that the brain is free of potential alterations during SVC clamping without CPB. Furthermore, under conditions of normothermic ischemia, the brain does not receive the protective benefit of hypothermia. ⁵ Without brain protection, even short intervals of low cerebral perfusion could generate minor or subclinical deficits that might be detectable only through detailed cognitive testing. We agree with Jonas’ comments that the demonstration of safety of this procedure will rest on the careful documentation of the neurodevelopmental and cognitive outcome of these patients.

doi:10.1067/mtc.2000.104869

References

1. Jahangiri M, Keogh B, Shinebourne EA, Lincoln C. Should the bidirectional Glenn procedure be performed through a thoracotomy without cardiopulmonary bypass? J Thorac Cardiovasc Surg 1999;118:367-8.[Free Full Text]
   
2. Rodriguez RA, Audenaert SM, Austin EH III, Edmonds LH Jr. Auditory evoked responses in children during hypothermic cardiopulmonary bypass: report of cases. J Clin Neurophysiol 1995;12:168-76.[Medline]
   
3. Rodriguez RA, Cornel G, Semelhago L, Spinter WM, Weerasena NA. Cerebral effects in superior venal caval cannula obstruction: the role of brain monitoring. Ann Thorac Surg 1997;64:1820-2.[Abstract/Free Full Text]
   
4. Kileny P, Dobson D, Gelfand ET. Middle-latency auditory evoked responses during open-heart surgery with hypothermia. Electroenceph Clin Neurophysiol 1983;55:268-76.[Medline]
   
5. Benita M, Condé H. Effects of local cooling upon conduction and synaptic transmission. Brain Res 1972;36:133-51.[Medline]
   

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This Article 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): Rosendo A. Rodriguez Garry Cornel Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Rodriguez, R. A. Articles by Cornel, G. Search for Related Content PubMed PubMed Citation Articles by Rodriguez, R. A. Articles by Cornel, G.