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Updated: Jun 14, 2025
Hemodynamic Precision in the Neonatal Intensive Care Unit using Targeted Neonatal Echocardiography
Published on: January 27, 2023
Resuscitation arterial waveform quantification and outcomes in pediatric bidirectional Glenn and Fontan patients
Andrew R Yates1, David A Hehir2, Ron W Reeder3
1Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA. Andrew.yates@nationwidechildrens.org.
Insights
Cardiopulmonary resuscitation (CPR) outcomes differ between Bidirectional Glenn (BDG) and Fontan physiology patients. BDG patients had better diastolic blood pressure and neurologic outcomes, though half experienced new morbidity.
Area of Science:
- Pediatric Cardiology
- Critical Care Medicine
- Congenital Heart Disease
Background:
- Resuscitation in Bidirectional Glenn (BDG) or Fontan physiology may worsen neurologic injury.
- Passive venous return can be compromised during CPR in these unique anatomies.
Purpose of the Study:
- To compare arterial pressure and survival rates in BDG versus Fontan patients undergoing CPR.
- To investigate the impact of CPR on neurologic outcomes in single ventricle physiology.
Main Methods:
- Secondary analysis of the Pediatric Intensive Care Quality of CPR and Improving Outcomes from Pediatric Cardiac Arrest databases.
- Evaluation of hemodynamic waveforms and patient outcomes from 2 prospective observational studies.
- Comparison of diastolic blood pressure and survival with favorable neurologic outcome between BDG and Fontan groups.
Main Results:
- BDG patients (66%) had higher rates of return of spontaneous circulation (76%) than Fontan patients (34%, 59%).
- Survival with favorable neurologic outcome was higher in BDG (52%) versus Fontan patients (27%, p=0.067).
- Adequate diastolic blood pressure (≥25-30 mmHg) was achieved more frequently in BDG (91%) than Fontan patients (46%, p=0.007).
Conclusions:
- Fontan patients had poor survival with favorable neurologic outcome (27%) after CPR, potentially due to inadequate diastolic blood pressure.
- Half of surviving BDG patients experienced new neurologic morbidity post-discharge.
- CPR management and outcomes vary significantly based on single ventricle congenital heart disease anatomy.
Background:
Resuscitation with chest compressions and positive pressure ventilation in Bidirectional Glenn (BDG) or Fontan physiology may compromise passive venous return and accentuate neurologic injury. We hypothesized that arterial pressure and survival would be better in BDG than Fontan patients.
Methods:
Secondary analyses of the Pediatric Intensive Care Quality of CPR and Improving Outcomes from Pediatric Cardiac Arrest databases. P-values were considered significant if < 0.05.
Results:
In total, 64 patients had either BDG (42/64, 66%) or Fontan (22/64, 34%) anatomy. Return of spontaneous circulation was achieved in 76% of BDG patients versus 59% of Fontan patients and survival with favorable neurologic outcome in 22/42 (52%) BDG versus 6/22 (27%) Fontan patients, p = 0.067. Twelve of 24 (50%) BDG and 2/7 (29%) Fontan patients who survived to discharge suffered new morbidity as defined by worsening Functional Status Score. More BDG patients achieved adequate DBP (≥25 mmHg for neonates and infants; ≥ 30 mmHg for children) than Fontan patients (21/23 (91%) vs. 5/11 (46%), p = 0.007).
Conclusions:
Only 27% of Fontan patients survived to hospital discharge with favorable neurologic outcome after CPR, likely driven by inadequate diastolic blood pressure during resuscitation. One half of the BDG patients who survived to hospital discharge had new neurologic morbidity.
Impact Statement:
Hemodynamic waveforms from 2 large prospective observational studies now allow for exploration of physiology during cardiopulmonary resuscitation for unique anatomy associated with single ventricle congenital heart disease. Fewer patients with Fontan physiology (46%) achieved an adequate diastolic blood pressure (defined as ≥ 25 mmHg for neonates and infants and ≥ 30 mmHg for children) than bidirectional Glenn patients during cardiopulmonary resuscitation (91%, p = 0.007). Only 27% of Fontan patients survived to hospital discharge with favorable neurologic outcome after cardiopulmonary resuscitation. Of the bidirectional Glenn patients who survived, 50% developed a new morbidity as quantified by the Functional Status Score.
