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

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
03 February 2022