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Early bidirectional cavopulmonary shunt in young infants. Postoperative course and early results
A C Chang1, F L Hanley, G Wernovsky
1Department of Cardiology, Children's Hospital, Boston, MA 02115.
Insights
Bidirectional cavopulmonary shunt surgery in infants under six months old shows promising results, improving oxygen saturation with low mortality. This early intervention may lead to better outcomes for future Fontan procedures.
Area of Science:
- Pediatric Cardiac Surgery
- Congenital Heart Disease Management
- Cardiovascular Physiology
Background:
- Limited data exists on bidirectional cavopulmonary shunt (BCPS) in infants younger than six months.
- BCPS is increasingly used for complex congenital heart defects.
Purpose of the Study:
- To evaluate the safety and efficacy of early BCPS in infants aged 6 months or younger.
- To assess early outcomes, including survival, morbidity, and physiological improvements.
Main Methods:
- Retrospective review of 17 infants (4.2-6.5 months) undergoing BCPS before October 1992.
- Analysis of diagnoses, prior surgeries, indications for BCPS, and pre/postoperative parameters.
Main Results:
- Overall hospital survival was 94% (1 death).
- Postoperative oxygen saturation improved significantly (median 75% to 85%).
- Transient systemic hypertension was the most common complication (88%).
Conclusions:
- Early BCPS in young infants is safe and effective, offering improved oxygenation.
- Elective early BCPS may mitigate risks associated with chronic hypoxemia and ventricular overload.
- This approach potentially creates more suitable candidates for subsequent Fontan operations.
Background:
Despite the recent wide applicability of the bidirectional cavopulmonary shunt, there is limited reported experience in performing these shunts in infants 6 months or younger.
Methods And Results:
Before October 1992, 17 consecutive infants aged 4.2 to 6.5 months (median, 6.1 months) underwent bidirectional cavopulmonary shunts. The diagnoses were hypoplastic left heart syndrome (n = 7), single right ventricle (n = 5), and single left ventricle (n = 5). All but 2 patients had prior palliative surgery. The bidirectional cavopulmonary shunt was performed early on an elective basis in 9 patients; the remaining patients had progressive cyanosis (6 patients), severe ventricular failure (1 patient), and coexisting restrictive bulboventricular foramen (1 patient). The median preoperative pulmonary arterial pressure and pulmonary vascular resistance were 15 mm Hg and 2.3 U.m2, respectively. One patient died; the overall hospital survival was 94%. The most common postoperative problem was transient systemic hypertension, observed in 14 (88%) of 16 survivors. Systemic arterial oxygen saturation increased from a median of 75% before surgery to a median of 85% after surgery (P < .05). The median hospital stay was 6 days. There were no late deaths during follow-up (median, 12.4 months). At postoperative cardiac catheterization performed in 9 of 16 survivors, there was no evidence of severe hypoxemia, shunt narrowing, or pulmonary arteriovenous fistulas. Of the 16 survivors, 6 have had a subsequent Fontan operation at a median age of 1.9 years; there were 5 survivors.
Conclusions:
Early bidirectional cavopulmonary shunt in young infants has shown encouraging early results and provides improved oxygenation with low morbidity and mortality. We speculate that an early bidirectional cavopulmonary shunt on an elective basis may reduce the deleterious sequelae of chronic hypoxemia, long-term ventricular volume overload, and repeated palliative procedures, thus yielding a more suitable Fontan candidate.