The Failed Bidirectional Glenn Shunt: Risk Factors for Poor Outcomes and the Role of Early Reoperation

Background: Bidirectional Glenn shunt (BDG) failure carries high morbidity and mortality but the clinical factors associated with failure and the optimal management strategy are understudied. Methods: A total of 217 patients undergoing BDG at our institution between 1989 and 2020 were retrospectively reviewed and categorized as success or failure. Failure was defined as the need for reoperation (BDG takedown, reoperation for correction of cardiac defect, and/or transplantation) at any time postoperatively; operative mortality (death attributable to BDG malfunction occurring during the index hospitalization for BDG or within 30 days of discharge); or late mortality (death directly attributable to BDG malfunction occurring prior to Fontan or next-stage palliation). Univariate and binary logistic regression analyses were performed. Results: BDG failure occurred in 14 (6.5%) patients. Univariate predictors were: hypoplastic left heart syndrome ( P = .037), right ventricular (RV) dominance ( P = .010), greater pre-BDG pulmonary vascular resistance (PVR) ( P = .012), concomitant atrioventricular valve repair ( P = .020), prolonged pleural drainage ( P = .001), intensive care unit ( P<.001) and hospital ( P = .002) stays, and extracorporeal membrane oxygenation (ECMO) requirement ( P<.001). Multivariate predictors were: RV dominance ( P = .002), greater PVR ( P = .041), ICU ( P<.001) and hospital ( P = .020) stays, and need for ECMO ( P<.001). As many as 10 of 14 (71%) patients with BDG failure died. Reoperation was performed for 10 patients with BDG failure. Five reoperation patients survived until discharge, with four patients alive at last follow-up (mean 7.9 years). Survivors underwent reoperation earlier than nonsurvivors (36 vs. 94 days). Conclusions: BDG failure carries high mortality, but preoperative predictors and postoperative indicators of failure exist. Early BDG takedown and insertion of aorta-pulmonary shunt may allow survival.

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Effectiveness of Bidirectional Glenn Shunt Placement for Palliation in Complex Congenitally Corrected Transposed Great Arteries

Texas Heart Institute Journal ◽

10.14503/thij-17-6555 ◽

2020 ◽

Vol 47 (1) ◽

pp. 15-22

Author(s):

Kai Ma ◽

Lei Qi ◽

Zhongdong Hua ◽

Keming Yang ◽

Hao Zhang ◽

...

Keyword(s):

Glenn Shunt ◽

Shunt Placement ◽

Anatomic Repair ◽

Bidirectional Glenn ◽

Palliative Procedure ◽

Bidirectional Glenn Shunt ◽

Group 3 ◽

Congenitally Corrected Transposition ◽

Corrected Transposition

Surgery for complex congenitally corrected transposed great arteries is one of the greatest challenges in cardiovascular surgery. We report our experience with bidirectional Glenn shunt placement as a palliative procedure for complex congenitally corrected transposition. We retrospectively identified 50 consecutive patients who had been diagnosed with congenitally corrected transposition accompanied by left ventricular outflow tract obstruction and ventricular septal defect and who had then undergone palliative bidirectional Glenn shunt placement at our institution from January 2005 through December 2014. Patients were divided into 3 groups according to subsequent surgeries: Fontan completion (total cavopulmonary connection, 13 patients) (group 1), anatomic repair (hemi-Mustard and Rastelli procedures without Glenn takedown, 11 patients) (group 2), and prolonged palliation (no further surgery, 26 patients) (group 3). After shunt placement, no patient died or had ventricular dysfunction. Overall, mean oxygen saturation increased significantly from 79.5% ± 13.5% preoperatively to 94.1% ± 7.3% (P <0.001). The median time from shunt placement to Fontan completion and anatomic repair, respectively, was 2.1 years (range, 1.6–5.2 yr) and 1.1 years (range, 0.6–2.4 yr). Only 2 late deaths occurred, both in group 1. In group 3, time from shunt placement to latest follow-up was 4.5 years (range, 2.3–8 yr). At latest follow-up, mean oxygen saturation was 91.6% ± 10.3%, and no patients had impaired ventricular function. Bidirectional Glenn shunt placement as an optional palliative procedure for complex congenitally corrected transposition has favorable outcomes. Later, patients can feasibly be treated by Fontan completion or anatomic repair. Use of a bidirectional Glenn shunt for open-ended palliation is also acceptable.

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Role of alpha adrenergic antagonism in a child with a bidirectional Glenn shunt undergoing cleft palate repair

Annals of Cardiac Anaesthesia ◽

10.4103/0971-9784.41586 ◽

2008 ◽

Vol 11 (2) ◽

pp. 132

Author(s):

MadanMohan Maddali ◽

ValakatteSeetharam Vinayakumar ◽

Chona Thomas

Keyword(s):

Cleft Palate ◽

Glenn Shunt ◽

Bidirectional Glenn ◽

Bidirectional Glenn Shunt ◽

Cleft Palate Repair ◽

Palate Repair

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Bidirectional Glenn for residual outflow obstruction in Tetralogy of Fallot

Cardiology in the Young ◽

10.1017/s1047951119000866 ◽

2019 ◽

Vol 29 (5) ◽

pp. 684-688

Author(s):

Kamal Saleem ◽

Iftikhar Ahmed ◽

Mehboob Sultan ◽

Intisar ul Haq ◽

Umair Younus ◽

...

Keyword(s):

Right Ventricular ◽

Tetralogy Of Fallot ◽

Pulmonary Insufficiency ◽

Outflow Obstruction ◽

Glenn Shunt ◽

Bidirectional Glenn ◽

Bidirectional Glenn Shunt ◽

Ventricular Outflow Obstruction ◽

Tetralogy Of Fallot Repair

AbstractBackground:Residual right ventricular outflow obstruction during Tetralogy of Fallot repair necessitates peri-operative revision often requiring trans-annular patch with its negative sequels. Bidirectional Glenn shunt in this setting reduces trans-pulmonary gradient to avoid revision.Methods:Bidirectional Glenn shunt was added during Tetralogy repair in patients with significant residual obstruction. A total of 53 patients between January, 2011 and June, 2018 were included. Final follow-up was conducted in July, 2018.Results:Mean age at operation was 5.63±3.1 years. Right to left ventricular pressure ratio reduced significantly (0.91±0.09 versus 0.68±0.05; p<0.001) after bidirectional Glenn, avoiding revision in all cases. Glenn pressures at ICU admission decreased significantly by the time of ICU discharge (16.7±3.02 versus 13.5±2.19; p<0.001). Pleural drainage ≥ 7 days was seen in 14 (26.4%) patients. No side effects related to bidirectional Glenn-like facial swelling or veno-venous collaterals were noted. Mortality was 3.7%. Discharge echocardiography showed a mean trans-pulmonary gradient of 32.11±5.62 mmHg that decreased significantly to 25.64±5 (p<0.001) at the time of follow-up. Pulmonary insufficiency was none to mild in 45 (88.2%) and moderate in 6 (11.8%). Mean follow-up was 36.12±25.15 months (range 0.5–90). There was no interim intervention or death. At follow-up, all the patients were in NYHA functional class 1 with no increase in severity of pulmonary insufficiency.Conclusion:Supplementary bidirectional Glenn shunt significantly reduced residual right ventricular outflow obstruction during Tetralogy of Fallot repair avoiding revision with satisfactory early and mid-term results.

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Novel techniques of bidirectional Glenn shunt without cardiopulmonary bypass

The Annals of Thoracic Surgery ◽

10.1016/s0003-4975(99)00278-7 ◽

1999 ◽

Vol 67 (6) ◽

pp. 1771-1774 ◽

Cited By ~ 28

Author(s):

Kona Samba Murthy ◽

Robert Coelho ◽

Shivaprakasha K Naik ◽

Anil Punnoose ◽

Wilson Thomas ◽

...

Keyword(s):

Cardiopulmonary Bypass ◽

Glenn Shunt ◽

Bidirectional Glenn ◽

Bidirectional Glenn Shunt

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Successful surgical repair of Uhl's anomaly

Cardiology in the Young ◽

10.1017/s1047951102000410 ◽

2002 ◽

Vol 12 (2) ◽

pp. 192-195 ◽

Cited By ~ 15

Author(s):

Nawal Azhari ◽

Mervat Assaqqat ◽

Ziad Bulbul

Keyword(s):

Right Ventricle ◽

Surgical Repair ◽

Total Cavopulmonary Connection ◽

Thromboembolic Stroke ◽

Glenn Shunt ◽

Bidirectional Glenn ◽

Bidirectional Glenn Shunt ◽

Patch Closure ◽

The Right ◽

Cavopulmonary Connection

We report a case of Uhl's anomaly in a 5-month-old cyanotic infant who presented with thromboembolic stroke and acute hemiparesis. The patient underwent successfully an initial surgical repair, which included exclusion of the right ventricle by patch closure of the tricuspid valve, atrial septectomy and construction of a bidirectional Glenn shunt. This was followed by successful construction of a total cavopulmonary connection.

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Predictors of the development of takotsubo cardiomyopathy in aneurysmal subarachnoid hemorrhage and outcomes in patients with intra-aortic balloon pumps

Journal of Neurosurgery ◽

10.3171/2020.5.jns20536 ◽

2020 ◽

pp. 1-6

Author(s):

Joshua S. Catapano ◽

Andrew F. Ducruet ◽

Fabio A. Frisoli ◽

Candice L. Nguyen ◽

Christopher E. Louie ◽

...

Keyword(s):

Risk Factors ◽

Subarachnoid Hemorrhage ◽

Takotsubo Cardiomyopathy ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Multivariate Logistic Regression Analysis ◽

High Morbidity ◽

Female Patients ◽

Neurological Outcomes ◽

Poor Outcomes

OBJECTIVETakotsubo cardiomyopathy (TC) in patients with aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality. Previous studies have shown that female patients presenting with a poor clinical grade are at the greatest risk for developing TC. Intra-aortic balloon pumps (IABPs) are known to support cardiac function in severe cases of TC, and they may aid in the treatment of vasospasm in these patients. In this study, the authors investigated risk factors for developing TC in the setting of aSAH and outcomes among patients requiring IABPs.METHODSThe authors retrospectively reviewed the records of 1096 patients who had presented to their institution with aSAH. Four hundred five of these patients were originally enrolled in the Barrow Ruptured Aneurysm Trial, and an additional 691 patients from a subsequent prospectively maintained aSAH database were analyzed. Medical records were reviewed for the presence of TC according to the modified Mayo Clinic criteria. Outcomes were determined at the last follow-up, with a poor outcome defined as a modified Rankin Scale (mRS) score > 2.RESULTSTC was identified in 26 patients with aSAH. Stepwise multivariate logistic regression analysis identified female sex (OR 8.2, p = 0.005), Hunt and Hess grade > III (OR 7.6, p < 0.001), aneurysm size > 7 mm (OR 3, p = 0.011), and clinical vasospasm (OR 2.9, p = 0.037) as risk factors for developing TC in the setting of aSAH. TC patients, even with IABP placement, had higher rates of poor outcomes (77% vs 47% with an mRS score > 2, p = 0.004) and mortality at the last follow-up (27% vs 11%, p = 0.018) than the non-TC patients. However, aggressive intra-arterial endovascular treatment for vasospasm was associated with good outcomes in the TC patients versus nonaggressive treatment (100% with mRS ≤ 2 at last follow-up vs 53% with mRS > 2, p = 0.040).CONCLUSIONSTC after aSAH tends to occur in female patients with large aneurysms, poor clinical grades, and clinical vasospasm. These patients have significantly higher rates of poor neurological outcomes, even with the placement of an IABP. However, aggressive intra-arterial endovascular therapy in select patients with vasospasm may improve outcome.

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Effectiveness of the bidirectional Glenn shunt procedure for volume unloading in the single ventricle patient

The American Journal of Cardiology ◽

10.1016/0002-9149(94)90450-2 ◽

1994 ◽

Vol 74 (8) ◽

pp. 834-836 ◽

Cited By ~ 25

Author(s):

Norma L. Allgood ◽

Juan Alejos ◽

Davis C. Drinkwater ◽

Hillel Laks ◽

Roberta G. Williams

Keyword(s):

Single Ventricle ◽

Glenn Shunt ◽

Bidirectional Glenn ◽

Bidirectional Glenn Shunt ◽

Shunt Procedure

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Psychiatry’s ethical involvement in gender-affirming care

Australasian Psychiatry ◽

10.1177/1039856218775216 ◽

2018 ◽

Vol 26 (5) ◽

pp. 460-463 ◽

Cited By ~ 6

Author(s):

Roberto D’Angelo

Keyword(s):

Gender Dysphoria ◽

Poor Quality ◽

Medline Search ◽

Gender Reassignment ◽

The Subject ◽

Poor Outcomes ◽

Physical Treatments

Objective: To reflect on the role of psychiatry in authorising physical treatments for Gender Dysphoria and to examine the quality of evidence for gender-reassignment. Method: A Medline search was performed with the subject term “transsexualism” or “gender dysphoria” and “outcome” or “follow-up” in the title. Studies published from 2005 onwards reporting psychosocial outcomes were selected for review. Results: Most available evidence indicating positive outcomes for gender reassignment is of poor quality. The few studies with robust methodology suggest that some patients have poor outcomes and may be at risk of suicide. Conclusion: The author raises questions about the implications for ethical treatment of transgender individuals.

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