ABSTRACT

The bidirectional Glenn anastomosis has bee used as an effective mean of palliating complex heart defects, in those patients that doesn't meet the necessary criteria for prosecution of an atriopulmonary anastomosis. The surgery consists on anastomosing the superior caval vein (end to side anastomoses), in a way that the venous blood is distributed to both the right and left lungs. Between January and February, 1992, 20 patients have undergone the bidirectional anastomosis at the Instituto Dante Pazzanese de Cardiologia. Eight patients were female. Their ages ranged from 5 months to 8 years (mean age 37.7 months) and their weights ranged from 6.3 to 18.8 kg (means 12.4 kg). The surgical indication was considered primary in 10 cases. There were 8 patients with tricuspid atresia and 3 double inlet ventricles with highly diminished pulmonary blood flow considered not ideal candidates to a complete rapair. The other patients were considered secundary surgical indication. They had previous palliative operations such as systemic pulmonary shunts; pulmonary banding and atrialseptectomy (6 with tricuspid atresia, 3 double inlet ventricle with pulmonary stenosis or banding and 1 double intlet right ventricle with superior inferior ventricle). The surgery was performed with direction of the caval vein to right atrium in 12 cases and by means of cardiopulmonary bypass in 8. During the operation, the patients were monitored with a pulsatile oximeter. The mean preoperative arterial oxygen saturation was 75.5% (range 71 % to 86%) and postoperative 95% (range 91 % to 98%). No hospital death occurred. There was one late death caused by pulmonary infection two months after the surgery. We believe that the bidirectional Glenn anastomosis has its place as a first stage to a complete correction, because it doesn't increase cardiac work and pulmonary vascular resistence and is not associated with pulmonary arterial and anastomotic distortions as Blalock-Taussig does.

RESUMO

A cirurgia de Gleen bidirecional tem sido empregadacomo uma opção ao tratamento cirúrgico de pacientes considerados candidatos "não ideais" à cirurgia de derivação átrio-pulmonar. A operação consiste na anastomose da veia cava superior com a artéria pulmonar (anastomose término-lateral), permitindo o fluxo sanguíneo também para o pulmão contra-lateral. A partir de janeiro de 1990 até fevereiro de 1992, 20 pacientes foram operados em nosso Serviço, com idade variando de 5 meses a 8 anos (média de 37,7 meses). Oito pacientes eram do sexo feminino e o peso variou de 6,3 a 18,8 Kg (média - 12,4 kg). A indicação cirúrgica foi considerada primária em 10 casos. Sete casos de atresia tricúspide e 3 de ventrículo único, que apresentavam acentuada diminuição do fluxo pulmonar e não eram candidatos a correção total funcional. Os demais pacientes tiveram a indicação considerada secundária, ou seja, já haviam sido submetidos a operação de shunt artério-venoso, cerclagem do tranco pulmonar, ou atriosseptostomia, 8 casos de atresia tricúspide, 3 de ventrículo único com estenose ou cerclagem pulmonar e 1 caso de DVSVD com ventrículo superior-inferior). A operação foi realizada com desvio da veia cava-átrio direito em 12 casos e com o uso de CEC em 8. Durante o procedimento cirúrgico, os pacientes foram monitorizados com oxímetro pulsátil e a saturação de oxigênio média pré-correção foi de 75,5% (71% a 86%) e após, de 95% (91% a 98%). Não ocorreu óbito hospitalar e o único óbito tardio foi devido a infecção pulmonar no 2º mês de pós-operatório. Achamos, portanto, que a operação de Glenn bidirecional estará bem indicada como primeira etapa da correção definitiva, pois não aumenta o trabalho cardíaco e a resistência vascular pulmonar não produz distorções em artéria pulmonar como shunt tipo Blalock-Taussig.

REFERENCES

1. ABRAMS, L. - Superior vena cava-pulmonary artery anastomosis. Ann. Thorac. Surg., 37: 9-11, 1984. [MedLine]

2. ACHTEL, R. A.; KAPLAN, S.; BENZING, G.; HELMSWORTH, J. A. - Superior vena cava-right pulmonary artery anstomosis: long-term results. Ann. Thorac. Surg., 8: 511-519, 1969. [MedLine]

3. BAKULJEV, A.; KOLESNIKOV, S. A. - Anastomosis of superior vena cava and pulmonary artery in the surgical treatment of certain congenital of the heart. J. Thorac. Surg., 37: 693, 1959. [MedLine]

4. CALABRESE, C. T.; CARRINGTON, C. B.; HARLEY, R. A.; ROJAS, R. H.; GLENN, W. W. L. - Circulatory bypass of the right side of the heart. J. Surg. Res., 8: 593-600, 1968, [MedLine]

5. CARLON, C. A.; MONDINI, P. G.; de MARCHI, R. - Surgical treatment of some cardiovascular disease. J. Int. Coll. Surg., 16: 1-10, 1951.

6. De BRUX, J. L.; ZANNINI, L.; BINET, J. P. - Tricuspid atresia: results of treatment in 115 children. J. Thorac. Cardiovasc. Surg., 85: 440-446, 1982.

7. DeLEVAL, M. R.; BULL, C.; KILNER, P. - Total cavopulmonary connection: a logical alternative to atriopulmonary connection for complex Fontan operations: experimental studies and early clinical experience. Ann. Thorac. Surg., 46: 210-215,1988.

8. FONTAN, F. & BAUDET, E. - Surgical repair of tricuspid atresia. Thorax, 26: 240-248, 1971. [MedLine]

9. FONTAN, F.; De VILLE, C.; QUAEGEBEUR, J.; OTTEM KAMP, J.; SOURDILLE, N.; CHOUSSAT, A.; BROM, G. A. - Repair of tricuspid atresia in 100 patients. J. Thorac. Cardiovasc. Surg., 85: 647-660, 1983. [MedLine]

10. GLENN, W. W. L. - Circulatory bypass of the right side of the heart. IV. Shunt between superior vena cava and distal right pulmonary artery: report of clinical application. N. Engl. J. Med., 259: 117-120, 1958. [MedLine]

11. GRAHAM, A. J.; RICKETTS, H. J.; FENN, J. E.; LARSEN, P. B.; MUZAFFER, C.; GLENN, W. W. L. - Further experiments on long term survivors after circulatory bypass of the right side of the heart. Surg. Obstet. Gynecol., 119: 302-310, 1964.

12. HALLER, J. A.; ADKINS, J. C.; WORTHINGTON, M.; RAUENHORST, J. - Experimental studies on permanent bypass of the right heart. Surgery, 59: 1128-1132, 1966. [MedLine]

13. KAWASHIMA, Y.; KITAMURA, S.; MATSUDA, H.; SHIMAZAKI, Y.; NAKANO, S.; HIROSE, H. - Total cavopulmonary shunt operation in complex cardiac anomalies. J. Thorac. Cardiovasc. Surg., 87: 74-81-87, 1984.

14. KING, R. M.; PUGA, F. J.; DANIELSON, G. K. - Extende indications for the modified Fontan procedure in patients with anomalous systemic and pulmonary venous return. In. DOYLE, E. F.; ENGLE, M. A.; GERSONY, W. M.; RASHKIND, W. J.; TULNER, N. S. (eds.) Proceedings of the Second World Congress of Pediatric Cardiology. New York, Springer-Verlag, 1985.

15. KREUTZER, F. A. - Atriopulmonary anastomosis. J. Thorac. Cardiovasc. Surg., 83: 427-436, 1982. [MedLine]

16. LAKS, H.; MUDD, G. J.; STANDEVEN, J. W.; WILLIAM, V. L. - Long-term effect of the superior vena cavapulmonary artery anastomosis on pulmonary blood flow. J. Thorac. Cardiovasc. Surg., 74: 253-260, 1977. [MedLine]

17. LAMBERTI, J. J.; SPICER, R. L.; WELDMAN, J. D.; GREHL, T. M.; THOMSON, D.; GIORGE, L.; KIRKPATRIC, S. E.; MATHEWSON, J. W. - The bidirectional cavopulmonary shunt. J. Thorac. Cardiovasc. Surg., 100: 22-30, 1990.

18. MAZZERA, E.; CORNO, A.; PICARDO, S.; DIDONATO, R.; MARINO, B.; COSTA, D.; MARCELLETTI, C. - Bidirectional cavopulmonary shunts: clinical applications as staged or definitive palliation. Ann. Thorac. Surg., 47: 415-420, 1989. [MedLine]

19. MESHALKIN, E. N. - Anastomosis of the superior vena cava with the pulmonary artery in patients with congenital heart disease with blood flow insufciency in the lesser circulation. Experiment. Eksp. Khirurgie, 1: 3, 1956.

20. NULAND, S. G.; GLENN, W. W. L; GUILFOIL, P. H. - Circulatory bypass of the right heart: III. Some observations on the long-term survivors. Surgery, 43: 184-201, 1958. [MedLine]

21. PATINO, J. F.; GLENN, W. W. L; GUILFOIL. P. H. - Circulatory bypass of the right heart: II. Further observations on vena caval-pulmonary artery shunts. Surg. Forum, 6: 189-193, 1955.

22. ROBCSEK, F.; TEMESVARI, A.; KADAR, R. L. - A new method for the treatment of congenital heart disease associated with impaired pulmonary circulation. Acta. Med. Scand., 154: 154-161, 1956.

23. SHUMACKER, H. B.; (discussion of Hurwitt, E.; YOUNG, D.; ECHER, D.) - Rationale of anastomosis of right auricular appendage to pulmonary artery in the treatment of tricuspid atresia. J. Thorac. Surg., 30: 503-512, 1955. [MedLine]

24. YOUNG, W. G.; SEALY, W. C.; HOUCK, W. S. - Superior vena cava-right pulmonary anastomosis in cyanotic heart disease. Ann. Surg., 157: 894-901, 1963. [MedLine]