Bi-directional cavopulmonary shunt: is accessory pulsatile flow, good or bad?

Wal, H. J. C. M. Van De; Ouknine, Ruth; Tamisier, Daniel; Lévy, Marilyne; Vouhé, Pascal; Leca, F

doi:10.1016/s1010-7940(99)00205-5

Cited by 42 publications

(36 citation statements)

References 18 publications

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“…The ABG adds a component of pulsatility to the pulmonary blood flow, which could potentially improve pulmonary vascular development and exercise tolerance. 17,28 Our study does indicate that for the shunt size studied, nozzle/shunt designs having a b larger than 0.72 may be problematic as pulmonary artery pressures above 18 mmHg coupled with high PVR is a factor for surgery failure and possible death for stage 2 patients. 5 The VAD used in the open-loop MCS was not intended to be a consistent model of ventricle dynamics, nor would that be appropriate, but rather it provided a sufficiently realistic source of flow and pulsatility for the experimental system.…”

Section: Discussionmentioning

confidence: 87%

In Vitro Assessment of the Assisted Bidirectional Glenn Procedure for Stage One Single Ventricle Repair

Zhou

Esmaily

Conover

et al. 2015

Cardiovasc Eng Tech

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This in vitro study compares the hemodynamic performance of the Norwood and the Glenn circulations to assess the performance of a novel assisted bidirectional Glenn (ABG) procedure for stage one single ventricle surgery. In the ABG, the flow in a bidirectional Glenn procedure is assisted by injection of a high-energy flow stream from the systemic circulation using an aorta-caval shunt with nozzle. The aim is to explore experimentally the potential of the ABG as a surgical alternative to current surgical practice. The experiments are directly compared against previously published numerical simulations. A multiscale mock circulatory system was used to measure the hemodynamic performance of the three circulations. For each circulation, the system was tested using both low and high values of pulmonary vascular resistance. Resulting parameters measured were: pressure and flow rate at left/right pulmonary artery and superior vena cava (SVC). Systemic oxygen delivery (OD) was calculated. A parametric study of the ratio of ABG nozzle to shunt diameter was done. We report time-based comparisons with numerical simulations for the three surgical variants tested. The ABG circulation demonstrated an increase of 30-38% in pulmonary flow with a 2-3.7 mmHg increase in SVC pressure compared to the Glenn and a 4-14% higher systemic OD than either the Norwood or the Glenn. The nozzle/shunt diameter ratio affected the local hemodynamics. These experimental results agreed with those of the numerical model: mean flow values were not significantly different (p > 0.05) while mean pressures were comparable within 1.2 mmHg. The results verify the approaches providing two tools to study this complicated circulation. Using a realistic experimental model we demonstrate the performance of a novel surgical procedure with potential to improve patient hemodynamics in early palliation of the univentricular circulation.

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Section: Discussionmentioning

confidence: 87%

In Vitro Assessment of the Assisted Bidirectional Glenn Procedure for Stage One Single Ventricle Repair

Zhou

Esmaily

Conover

et al. 2015

Cardiovasc Eng Tech

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“…The reported mortality and morbidity rates in patients with accessory flow differ among institutions. Van deWal and colleagues 20 reported no influence on the survival rate in a study of 205 patients with an average age of 5.6 years; McElhinney and colleagues 21 reported higher, yet statistically insignificant, mortality in a study of 160 patients with an average age of 7.8 months; and Mainwaring and colleagues 22 reported higher mortality in study of 149 patients with an average age of 10 months. 23 Earlier completion of Fontan was reported in patients with accessory flow, and it has been argued that if hepatic-factor is important for the prevention of pulmonary arteriovenous malformation, then having accessory pulsatile flow might represent an advantage.…”

Section: Discussionmentioning

confidence: 96%

“…Adopting a systemically derived accessory pulmonary flow in the BDG circulation has been reported previously both clinically and investigationally, 20–23 although typically not during the neonatal period. The reported mortality and morbidity rates in patients with accessory flow differ among institutions.…”

Section: Discussionmentioning

confidence: 99%

“…23 Earlier completion of Fontan was reported in patients with accessory flow, and it has been argued that if hepatic-factor is important for the prevention of pulmonary arteriovenous malformation, then having accessory pulsatile flow might represent an advantage. 20 In addition, it has been suggested that accessory flow may improve exercise tolerance by providing a variable pulmonary flow. 24 …”

Section: Discussionmentioning

confidence: 99%

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The assisted bidirectional Glenn: A novel surgical approach for first-stage single-ventricle heart palliation

Esmaily

Hsia

Marsden

2015

The Journal of Thoracic and Cardiovascular Surgery

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Background: Outcomes after a modified Blalock-Taussig shunt (mBTS) in neonates with single-ventricle physiology remain unsatisfactory. However, initial palliation with a superior cavopulmonary connection, such as a bidirectional Glenn (BDG), is discouraged, owing to potential for inadequate pulmonary blood flow (PBF). We tested the feasibility of a novel surgical approach, adopting the engineering concept of an ejector pump, whereby the flow in the BDG is ‘‘assisted’’ by injection of a high-energy flow stream from the systemic circulation. Methods: Realistic 3-dimensional models of the neonatal mBTS and BDG circulations were created. The ‘‘assisted’’ bidirectional Glenn (ABG) consisted of a shunt between the right innominate artery and the superior vena cava (SVC), with a 1.5-mm clip near the SVC anastomosis to create a Venturi effect. The 3 models were coupled to a validated hydraulic circulation model, and 2 pulmonary vascular resistance (PVR) values (7 and 2.3 Wood units) were simulated. Results: The ABG provided the highest systemic oxygen saturation and oxygen delivery at both PVR levels. In addition to achieving higher PBF than the BDG, the ABG produced a lower single-ventricular workload than mBTS. SVC pressure was highest in the ABG model (ABG: 15; Glenn: 11; mBTS: 3 mm Hg; PVR = 7 Wood units), but at low PVR, the SVC pressure was significantly lower (ABG: 8; Glenn: 6; mBTS:<3 mm Hg). Conclusions: Adopting the principle of an ejector pump, with additional flow directed into the SVC in a BDG, the ABG appears to increase PBF with a modest increase in SVC and pulmonary arterial pressure. Although multiscale modeling results demonstrate the conceptual feasibility of the ABG circulation, further technical refinement and investigations are necessary, especially in an appropriate animal model. (J Thorac Cardiovasc Surg 2015;149:699–705)

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“…Advocates of antegrade flow point out the higher oxygen saturations that result, as well as the theoretical effect of pulsatile flow on enhancing pulmonary artery growth [27,28]. Proponents of eliminating antegrade blood flow report a reduction in the extent and duration of postoperative pleural effusions as well as the difficulty in establishing how much antegrade blood flow is too much [29].…”

Section: Second Stage Palliationmentioning

confidence: 99%