Management of Failing Bidirectional Cavopulmonary Shunt: Impact of Additional Systemic to Pulmonary Artery Shunt with Classic Glenn Physiology

Background: Hypoxemia in the early postoperative period after bidirectional cavopulmonary shunt (BCPS) is a critical complication. We aimed to evaluate patients who underwent additional systemic to pulmonary shunt and septation of central pulmonary artery (partial takedown) after BCPS.

Method: The medical records of the patients who underwent BCPS between 2007 and 2020 were reviewed. Patients who underwent partial takedown were extracted and evaluated.

Results: Of 441 BCPS patients, 26 patients (6%) required partial takedown. Most frequent diagnosis was hypoplastic left heart syndrome (n = 13, 50%) and most frequent stage I palliation was Norwood procedure (n = 17, 65%). Additional complicating factors included pulmonary artery (PA) hypoplasia (n = 12), pulmonary venous obstruction (PVO, n = 3), or high PA pressure > 15 mm Hg (n = 4). Twelve patients underwent partial takedown on the same day of BCPS and survived. The remaining 14 patients (54%) received partial takedown between postoperative days 1 and 64. Reasons for partial takedown were postoperative high pulmonary vascular resistance (n = 4), early BCPS (< 90 days) with PA hypoplasia (n = 3), mediastinitis/pneumonia (n = 3), PVO (n = 2), ventricular dysfunction (n = 1), and recurrent pneumothorax (n = 1). Four patients died in the hospital. All 22 hospital survivors were followed up for a median of 22 months. Six patients died after discharge, 10 achieved Fontan completion, and 5 were alive and waiting for Fontan. PVO (p = 0.041) and genetic/extracardiac anomalies (p = 0.085) were identified as risks for mortality after partial takedown.

Conclusion: Partial takedown after BCPS with unilateral Glenn and contralateral systemic to pulmonary shunt is a successful alternative to complete takedown for patients with inadequate pulmonary perfusion. Fontan completion can be achieved in more than half of the patients ([Table 1]).

Table 1 Preoperative variables influencing survival after partial takedown with Cox regression model

Variables	Univariate model			Multivariate model
	p-Value	HR	95% CI	p-Value	HR	95% CI
UAVSD	0.031	4.662	1.2–18.8
Genetic/extracardiac anomaly	0.053	3.369	1.0–11.5	0.085	4.321	0.8–22.8
PAP >15 mm Hg	0.079	4.436	0.8–23.4
PVO	0.021	10.499	1.4–72.7	0.041	8.936	1.1–73.1
PTD on separate days	0.057	3.675	1.0–14.0

Publication History

Article published online:
03 February 2022