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J Thorac Cardiovasc Surg 2008;135:1405
© 2008 The American Association for Thoracic Surgery

Letter to the Editor

Grey zone area for Glenn and future Fontan candidates

Sameh Ibrahim Sersar, MD

Division of Cardiothoracic Surgery, Department of Cardiovascular Diseases, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia

To the Editor:

We enjoyed the very good article by Scheurer and colleagues.1Go We have a few comments.

Inhaled nitric oxide produces significant reduction in Glenn pressures and improvement in systemic perfusion and pulmonary gas exchange in patients with marked increases of Glenn pressures after bidirectional Glenn anastomosis. Patients who do not respond should be investigated for an anatomic lesion.2Go

Glenn shunt mortality was higher with surgical intervention before age 120 days but was not affected by surgical intervention during the respiratory virus season. Operations in the youngest age groups might adversely affect mortality.3Go

There were no differences in morbidity and mortality outcomes after the bidirectional Glenn operation between the Norwood-Right ventricle to pulmonary artery and Norwood-Blalock Taussig Shunt groups. Despite younger age at presentation, the Norwood-Right ventricle to pulmonary artery patients had better growth rate, which might have contributed to the similar postoperative outcomes.4Go

Atrial septal defects should be left open for all patients with severe right heart hypoplasia and in patients with postbypass right atrial pressures of more than 12 mm Hg.5Go

The advantages of incorporating a hypoplastic ventricle to partly support the pulmonary circulation are the following: (1) ability to increase the cardiac output; (2) adaptation to exercise; (3) maintenance of pulsatile flow in the pulmonary circulation; (4) flexibility to increased pulmonary vascular resistance; (5) circulation at low venous pressure in the Inferior Vena Cava system; and (6) capability of a hypoplastic right heart to adequately handle the reduced preload.6Go

There is a major debate for the gray-zone high-risk patients who do not fulfill the Choussat commandments. The current protocol in those patients is first to review all the data in detail. Full consideration is given as to whether there are any surgically (or interventionally) correctable lesions, such as atrioventricular valve regurgitation amenable to repair or isolated stenoses or hypoplasia within the central pulmonary arteries. Ventricular function, if impaired, might be optimized by altering medical management (vasodilators, diuretic therapy, and trial of oral enoximone, if appropriate). Evidence of increased pulmonary vascular resistance is treated with a course of pulmonary vasodilator therapy (sildenafil or bosentan). The patients are then reassessed for suitability for Fontan completion. The evidence would suggest that only 2 of the original 10 commandments of Choussat carry significant weight for both early and late outcome over the Fontan procedure and that they are preoperative ventricular function and preoperative pulmonary artery pressures of greater than 15 mm Hg.7Go

We found that right ventricular morphology; single ventricle; intact septum; semilunar valve abnormalities; diastolic dysfunction; myocardial hypertrophy, dilatation, or both; older age; bilateral superior vena cavae; pulmonary airway disease; and hypotonia all carry a worse prognosis and a tough postoperative course.

To be right ventricular morphology; single ventricle; intact septum; semilunar valve abnormalities; diastolic dysfunction; myocardial hypertrophy, dilatation, or both; older age; bilateral superior vena cavae; Interrupted IVC; pulmonary airway disease; and hypotonia all carry a worse prognosis and a tough postoperative course.

References

  1. Scheurer MA, Hill EG, Vasuki N, Maurer S, Graham EM, Bandisode V, et al. Survival after bidirectional cavopulmonary anastomosis: analysis of preoperative risk factors. J Thorac Cardiovasc Surg 2007;134:82-89.[Abstract/Free Full Text]
  2. Agarwal HS, Churchwell KB, Doyle TP, Christian KJ, Drinkwater DC, Byrne DW, et al. Inhaled nitric oxide use in bidirectional Glenn anastomosis for elevated Glenn pressures. Ann Thorac Surg 2006;81:1429-1434.[Abstract/Free Full Text]
  3. Nicolas RT, Hills C, Moller JH, Huddleston CB, Johnson MC. Early outcome after Glenn shunt and Fontan palliation and the impact of operation during viral respiratory season: analysis of a 19-year multi-institutional experience. Ann Thorac Surg 2005;79:613-617.[Abstract/Free Full Text]
  4. Lai L, Laussen PC, Cua CL, Wessel DL, Costello JM, del Nido PJ, et al. Outcomes after bidirectional Glenn operation: Blalock-Taussig shunt versus right ventricle–to–pulmonary artery conduit. Ann Thorac Surg 2007;83:1768-1773.[Abstract/Free Full Text]
  5. Chowdhury UK, Airan B, Sharma R, Bhan A, Kothari SS, Saxena A, et al. One and a half ventricle repair with pulsatile bidirectional Glenn: results and guidelines for patient selection. Ann Thorac Surg 2001;71:1995-2002.[Abstract/Free Full Text]
  6. Stellina G, Vidaa VL, Milanesi B, Rubinoa, Padalinoa, Secchierib S, et al. Surgical treatment of complex cardiac anomalies: the "one and one half ventricle repair". Eur J Cardiothorac Surg 2002;22:431-437.[Abstract/Free Full Text]
  7. Hosein RBM, Clarke AJB, McGuirk SP, Griselli M, Stumper O, Giovanni JVDe, et al. Factors influencing early and late outcome following the Fontan procedure in the current era. The "two commandments"?. Eur J Cardiothorac Surg 2007;31:344-353.[Abstract/Free Full Text]




This Article
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