Superior Cavopulmonary Connection: Its Physiology, Limitations, and Anesthetic Implications

2020 ◽  
Vol 24 (4) ◽  
pp. 337-348
Author(s):  
Ray S. Choi ◽  
James A. DiNardo ◽  
Morgan L. Brown
Keyword(s):  
Blood Flow ◽  
Pulmonary Blood Flow ◽  
Single Ventricle ◽  
Fontan Procedure ◽  
Intermediate Stage ◽  
Ventricular Volume ◽  
Volume Load ◽  
Modes Of Failure ◽  
Anesthetic Considerations ◽  
Cavopulmonary Connection

The superior cavopulmonary connection (SCPC) or “bidirectional Glenn” is an integral, intermediate stage in palliation of single ventricle patients to the Fontan procedure. The procedure, normally performed at 3 to 6 months of life, increases effective pulmonary blood flow and reduces the ventricular volume load in patients with single ventricle (parallel circulation) physiology. While the SCPC, with or without additional sources of pulmonary blood flow, cannot be considered a long-term palliation strategy, there are a subset of patients who require SCPC palliation for a longer interval than the typical patient. In this article, we will review the physiology of SCPC, the consequences of prolonged SCPC palliation, and modes of failure. We will also discuss strategies to augment pulmonary blood flow in the presence of an SCPC. The anesthetic considerations in SCPC patients will also be discussed, as these patients may present for noncardiac surgery from infancy to adulthood.

scholarly journals The Fontan Procedure for Single-Ventricle Physiology

2018 ◽  
Vol 38 (1) ◽  
pp. e1-e10 ◽  
Author(s):  
Melissa Beaudet Jones
Keyword(s):  
Blood Flow ◽  
Pulmonary Blood Flow ◽  
Single Ventricle ◽  
Fontan Procedure ◽  
Clinical Status ◽  
Pulmonary Arteries ◽  
Pressure Gradients ◽  
Single Ventricle Physiology ◽  
Systemic Venous Return ◽  
Postoperative Problems

The Fontan procedure is the final procedure in staged palliation for patients with functional single-ventricle physiology. The goal of the procedure is to separate systemic and pulmonary blood flow by directing systemic venous return through the Fontan connection to the pulmonary arteries and the lungs without ventricular contribution. Following the procedure, pulmonary blood flow is completely passive and dependent on pressure gradients, resulting in complex postoperative cardiopulmonary interactions. Understanding the physiology is essential to effectively manage these patients. Critical care nurses caring for patients after a Fontan procedure must understand preoperative data, risk factors, and unique postoperative physiology so they can anticipate specific postoperative problems, recognize trends in clinical status, and develop an appropriate plan of care. This paper reviews the first 2 stages of single-ventricle palliation, relevant modifications to the Fontan procedure, important preoperative cardiac catheterization data, common postoperative problems, and outcomes after the Fontan procedure.

Pulmonary blood flow distribution after the total cavopulmonary connection for complex cardiac anomalies

1999 ◽  
Vol 14 (3) ◽  
pp. 154-160 ◽  
Author(s):  
Masao Tayama ◽  
Nobuaki Hirata ◽  
Tohru Matsushita ◽  
Tetsuya Sano ◽  
Norihide Fukushima ◽  
...  
Keyword(s):  
Blood Flow ◽  
Pulmonary Blood Flow ◽  
Flow Distribution ◽  
Total Cavopulmonary Connection ◽  
Blood Flow Distribution ◽  
Cardiac Anomalies ◽  
Cavopulmonary Connection

Abstract 14860: Echocardiographic Assessment of Shunt Fraction in Complex Cyanotic Heart Diseases Palliated With Aortopulmonary Shunts

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Joan K Lee ◽  
briana olson ◽  
Neal Jorgensen ◽  
Matthew D Files
Keyword(s):  
Blood Flow ◽  
Pulmonary Blood Flow ◽  
Heart Diseases ◽  
Heart Defects ◽  
Ductus Arteriosus ◽  
Ventricular Volume ◽  
Systemic Circulation ◽  
Repeated Measurements ◽  
Observer Agreement ◽  
Shunt Fraction

Introduction: Neonates with complex heart defects with inadequate pulmonary blood flow require aortopulmonary shunts (APS) either as surgical-placed modified Blalock-Taussig shunt or a catheter-based stent implantation into a patent ductus arteriosus. An ideal APS provides equal pulmonary blood flow (Qp) as the systemic blood flow (Qs), which is considered balanced circulation. Pulmonary over-circulation leads to complications from inadequate systemic circulation, such as organ dysfunction, shock, and death. Accurately determining Qp:Qs ratio in these patients relies on catheterization, which is invasive and may falsely lower the Qp due to anesthetic effects. To our knowledge, there has not been any studies on echocardiographic comparisons of balanced versus overcirculated APS. We aim to evaluate echocardiographic Doppler assessment of velocity-time integral (VTI) at the aortic arch isthmus distal to APS origin as a measure of shunt fraction in APS patients. We defined shunt fraction ratio (SFR) as retrograde to prograde flow by VTI. Methods: This is a retrospective pilot study of neonates with APS. We selected two cohorts of patients with appropriately balanced circulation (n=12) and those with excessive Qp (n=5) resulting in end-organ damage. We analyzed serial echocardiograms, with repeated measurements for inter-observer agreement. Results: Mean SFR is lower in balanced cohort compared to the overcirculated cohort (0.45 ± 0.07 vs. 0.55 ± 0.09, p=0.02). For both groups, SFR was positively associated with oxygen saturation (r= 0.57, p=0.01), as well as markers of ventricular volume load, such as the highest brain naturetic peptide during hospitalization (Pearson’s correlation r=0.83, p= 0.04) and as outpatient (r= 0.72, p =0.02). Inter-observer agreement was 0.74, suggesting that this is a reproducible technique. Conclusions: SFR by VTI is a simple echocardiographic technique to estimate the volume of APS flow and appears to have important implications for clinical outcomes. Prompt characterization of pulmonary overcirculation without invasive assessment could improve clinical management. Further prospective studies are needed to validate these findings.

scholarly journals Bidirectional cavopulmonary connection without additional pulmonary blood flow in patients below the age of 6 months☆

2008 ◽  
Vol 34 (3) ◽  
pp. 556-562 ◽  
Author(s):  
Julie Cleuziou ◽  
Christian Schreiber ◽  
Juliane Karen Cornelsen ◽  
Jürgen Hörer ◽  
Andreas Eicken ◽  
...  
Keyword(s):  
Blood Flow ◽  
Pulmonary Blood Flow ◽  
Cavopulmonary Connection ◽  
Bidirectional Cavopulmonary Connection

Single-centre experience in stenting arterial shunts for adult CHD patients with single-ventricle physiology and pulmonary blood flow dependent on arterial shunts

2018 ◽  
Vol 28 (12) ◽  
pp. 1431-1435
Author(s):  
Mohamed Kasem ◽  
James Bentham ◽  
John Thomson
Keyword(s):  
Blood Flow ◽  
Pulmonary Blood Flow ◽  
Single Ventricle ◽  
Well Being ◽  
Adult Patients ◽  
P Value ◽  
Intermediate Step ◽  
Medium Term ◽  
Single Ventricle Physiology ◽  
Post Procedure

AbstractObjectivesThe objectives of this study were to describe the approach to stenting arterial shunts in adult congenital patients with single-ventricle physiology and to assess the medium-term clinical and haemodynamic outcomes following stent insertion.BackgroundAdult patients with single-ventricle physiology and pulmonary blood flow dependent on a surgically placed arterial shunt who did not progress to venous palliation are extremely challenging to manage. Progressive cyanosis secondary to narrowing of the shunt has a marked impact on exercise tolerance and results in intolerable well-being for these patients. Stenting arterial shunts in adult patients is one method that can help improve pulmonary blood flow. There is very limited information in the literature about this patient.MethodsThis is a retrospective study for arterial shunts stenting conducted between 2008 and 2016. The peripheral oxygen saturations, the NYHA status, the haemoglobin, and the degree of atrio-ventricular valve regurgitation as assessed on transthoracic echo were compared before and 6–12 months after procedures.ResultsThere was a short-term improvement in oxygen saturations; the pre-procedure mean was 75.8 (SD 2.55)% (range 70–85%) and post-procedure mean was 83 (SD 2.52)% (range 78–87%), with a p value of 0.04. Haemoglobin level decreased from a pre-procedure mean of 22.06–20.28 g/L 6 months post procedure (range 18.1–24.4 to 13–23.3 g/L), with a p value of 0.44. NYHA class decreased from a mean of 3.2–2.2 post procedure. Left atrial volume for four of the cases did not change (22.6–76.6 ml [mean 48.4 ml] to 29.6–72.9 ml [mean 52 ml], p value: 0.83).ConclusionsStenting stenotic arterial shunts is a useful method to gain a medium-term improvement on the oxygen saturation and clinical symptoms, and may act as a useful intermediate step for further management plans.

Effect of Accessory Pulmonary Blood Flow on Survival After the Bidirectional Glenn Procedure

Circulation ◽  
1999 ◽  
Vol 100 (suppl_2) ◽  
Author(s):  
Richard D. Mainwaring ◽  
John J. Lamberti ◽  
Karen Uzark ◽  
Robert L. Spicer ◽  
Mark W. Cocalis ◽  
...  
Keyword(s):  
Blood Flow ◽  
Mortality Rate ◽  
Pulmonary Blood Flow ◽  
Single Ventricle ◽  
Fontan Operation ◽  
Right Ventricular Outflow Tract ◽  
Bidirectional Glenn ◽  
Actuarial Analysis ◽  
Bidirectional Glenn Procedure ◽  
Glenn Procedure

Background —The bidirectional Glenn procedure (BDG) is used in the staged surgical management of patients with a functional single ventricle. Controversy exists regarding whether accessory pulmonary blood flow (APBF) should be left at the time of BDG to augment systemic saturation or be eliminated to reduce volume load of the ventricle. The present study was a retrospective review of patients undergoing BDG that was conducted to assess the influence of APBF on survival rates. Methods and Results —From 1986 through 1998, 149 patients have undergone BDG at our institution. Ninety-three patients had elimination of all sources of APBF, whereas 56 patients had either a shunt or a patent right ventricular outflow tract intentionally left in place to augment the pulmonary blood flow provided by the BDG. The operative mortality rate was 2.2% without APBF and 5.4% with APBF. The late mortality rate was 4.4% without APBF and 15.1% with APBF. Actuarial analysis demonstrates a divergence of the Kaplan-Meier curves in favor of patients in whom APBF was eliminated ( P <0.02). One hundred seven patients have subsequently undergone completion of their Fontan operation, so the actuarial analysis includes the operative risk of this second operation. Conclusions —The results suggest that the elimination of APBF at the time of BDG may confer a long-term advantage for patients with a functional single ventricle.

Endovascular stents for relief of cyanosis in single-ventricle patients with shunt or conduit-dependent pulmonary blood flow

2006 ◽  
Vol 68 (2) ◽  
pp. 280-286 ◽  
Author(s):  
Christopher J. Petit ◽  
Matthew J. Gillespie ◽  
Jacqueline Kreutzer ◽  
Jonathan J. Rome
Keyword(s):  
Blood Flow ◽  
Pulmonary Blood Flow ◽  
Single Ventricle ◽  
Endovascular Stents
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