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Impact of Evolving Surgical Strategy on Clinical Outcomes in Patients with Bilateral Superior Vena Cava Undergoing Bidirectional Cavopulmonary Shunt
Osami Honjo, Kim-Chi D Tran, Zhongdong Hua, Priya Sapra, Abdullah A Alghamdi, Ganeshakrishnan K Iyer, Osman O Al-Radi, John G Coles, Christopher A Caldarone, Glen S Van Arsdell
The Hospital for Sick Children, Toronto, ON, Canada
BACKGROUND:We have previously reported a high incidence of thrombus formation, central pulmonary artery hypoplasia and a subsequent higher morbidity and mortality for bilateral bidirectional cavopulmonary shunts (BBCPS). We hypothesized that modifying flow characteristics through technical modifications in the superior vena cava (SVC)-to-pulmonary artery (PA) anastomosis and the use of chronic anticoagulation would limit thrombus formation and preclude central PA hypoplasia thereby improving mortality.
METHODS:Sixty-one patients (median age, 8.4 months, weight, 6.6 kg) underwent BBCPS from 1990 to 2007. The cohort was divided into two: Group 1 n=37 (conventional BBCPS, '90-'99), and Group 2 n=24, (anastomosing the BBCPS immediately adjacent to each other on the PA so there was a V shaped appearance, or a Hemi-Fontan on one side and a BCPS on the other, '99-'07). Central and branch PA growth at pre-Fontan catheterization was determined.
RESULTS:See Table. Pre-BCPS assessment showed that Group 1 (conventional) was older(30+/-41 months vs. 10+/-14, p=0.007), weighed more(11.6+/-11kg vs.6.6+/-2.5, p=0.017), and had lower arterial saturation(71.5+/-5% vs. 79.4+/-4.2, p<0.0001). There were no differences in SVC and Nakata indices between the groups. Pre-Fontan assessment showed equivalent SVC and Nakata indices. The central PA index and subsequent central PA/Nakata index ratio were significantly higher in Group 2. There were no differences in freedom from death or transplant (Group 1 vs. Group 2, 75% vs. 86.7% at 1 year, 69.4% vs. 75.6% at 3 years, p=0.53), freedom from all re-interventions (78% vs. 81% at 1 year, 63% vs. 81% at 3 years, p=0.16), and freedom from SVC and/or PA thrombosis (82% vs. 95% at 1 year, p=0.11). On logistic regression, the risk factors for death included the presence of total anomalous pulmonary venous return (TAPVR) (p=0.02) and small SVC index (p=0.03). The risk factors for re-intervention included the conventional surgical technique (p=0.01), old age at repair (p=0.001), and small Nakata index (P=0.05). The risk factor for thrombus included small SVC (p=0.001), small Nakata index (p=0.03), and low arterial saturation after BBCPS (p=0.002).
CONCLUSIONS:Technical modifications for BBCPS were associated with improved central PA growth and less re-interventions after BBCPS. Risk for death and or thrombus was related to non-technical factors of TAPVR and a small SVC indexed size. A larger cohort would be required to determine if the trends of less thrombus formation and higher survival associated with the technical modifications are statistically real.
Comparison between conventional and V-shaped BCPS anastomosis | Group 1
Conventional (n=37) | Group 2
V-Shaped (n=24) | p value | | Pre-BCPS SVC index (mm2/m2) | 157+/-111 | 149+/-44 | 0.58 | | Pre-BCPS Nakata index (mm2/m2) | 250+/-114 | 273+/-139 | 0.414 | | SVC pressure after BCPS (mmHg) | 16.4+/-5.5 | 16.8+/-2.8 | 0.504 | | Arterial saturation after BCPS (%) | 78.9+/-9.7 | 79.3+/-7.7 | 0.799 | | Pre-Fontan SVC index (mm2/m2) | 151+/-89 | 188+/-75 | 0.45 | | Pre-Fontan Nakata index (mm2/m2) | 259+/-144 | 232+/-101 | 0.928 | | Central PA index (mm2/m2) | 76.5+/-73 | 116.8+/-88 | 0.042 | | Central PA/Nakata index ratio | 0.28+/-0.16 | 0.53+/-0.33 | 0.002 | | Pre-Fontan SVC pressure (mmHg) | 12.4+/-4.9 | 10.3+/-3.7 | 0.112 |
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