Surgical strategies to avoid Glenn physiology during staged left heart recruitment

Staged left ventricular recruitment can promote left ventricular growth through controlled volume loading. The optimal pulmonary blood flow source and the need for the bidirectional Glenn during staged left ventricular recruitment remain unclear. This study investigates staged left ventricular recruitment outcomes in patients who underwent staged left ventricular recruitment with or without the bidirectional Glenn.

This is a single-institution retrospective review of children undergoing staged left ventricular recruitment (2014-2024). Patients were stratified by pulmonary blood flow source: nonbidirectional Glenn (shunt/Sano upsize or pulmonary artery band alone) and bidirectional Glenn.

Eighty-eight patients underwent staged left ventricular recruitment with shunt upsizing (n = 11), pulmonary artery band (n = 9), or bidirectional Glenn/super-Glenn (n = 68). Median age at recruitment was 231 days (interquartile range, 495.25). Fundamental diagnosis was hypoplastic left heart syndrome/complex in 44 patients (50%). Median duration of recruitment was 642 days (576.5); duration was significantly lower in the nonbidirectional Glenn group compared with the bidirectional Glenn group (321 [480] days vs 754 [481] days) (P = .02). Forty-five patients (51.1%) achieved biventricular conversion, and 17 patients (19.3%) achieved 1.5-ventricle circulation. For the nonbidirectional Glenn, 90% reached biventricular circulation. Left ventricle indexed end-diastolic volume significantly increased during recruitment for the nonbidirectional Glenn (31.7 [28.6] mL/m² to 57.7 [34.5]) (P < .001) and bidirectional Glenn (22.7 [14.3] mL/m² to 48.5 [29.4]) (P < .001). Superior vena cava pressure significantly increased in the bidirectional Glenn group (9.5 [6] mm Hg to 16.5 [5] mm Hg) (P < .001) but not in the nonbidirectional Glenn group. Lymphatic complications occurred in 16% of patients and venovenous collaterals in 65% of patients in the bidirectional Glenn group. No patients in the nonbidirectional Glenn group experienced these problems.

Shunt upsizing and pulmonary artery band modification can be effective for ventricular volume loading during staged left ventricular recruitment, enabling biventricular conversion while avoiding potential complications of bidirectional Glenn physiology. These strategies should be considered in patients not anticipated to require prolonged recruitment and in patients deemed poor bidirectional Glenn candidates.