Right ventricle-to-pulmonary artery shunt related complications after Norwood procedure☆

Januszewska, Katarzyna; Kozlik‐Feldmann, Rainer; Dalla‐Pozza, Robert; Greil, Sabine; Abicht, Jan; Netz, Heinrich; Reichart, Bruno

doi:10.1016/j.ejcts.2010.10.038

Cited by 8 publications

(13 citation statements)

References 25 publications

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“…Potential explanations for differences in branch pulmonary artery growth patterns include anatomical abnormalities with the shunt or branch pulmonary arteries(16) and hemodynamic factors such as shunt diameter(12), as well as pulsatile versus non-pulsatile shunt blood flow(11). In contrast to our findings of inferior pulmonary artery growth in the RVPAS cohort, Januszewska and colleagues(17) reported that despite RVPAS subjects’ having a significantly lower Qp:Qs (0.8 vs. 1.2), lower aortic oxygen saturation (67.4% vs. 75.3%), and lower SVC oxygen saturation (43.5% vs. 49.7%), they had good, symmetric pulmonary artery growth prior to the stage II procedure. One purported advantage of the RVPAS is that it allows pulsatile flow into the branch pulmonary arteries, which may improve interstage pulmonary artery growth, as compared with the MBTS, which provides continuous flow.…”

Section: Discussioncontrasting

confidence: 99%

Impact of pre–stage II hemodynamics and pulmonary artery anatomy on 12-month outcomes in the Pediatric Heart Network Single Ventricle Reconstruction trial

Aiyagari

Rhodes

Shrader

et al. 2014

The Journal of Thoracic and Cardiovascular Surgery

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Objective To compare interstage cardiac catheterization hemodynamic and angiographic findings between shunt types for Single Ventricle Reconstruction (SVR) trial. Background The SVR trial, which randomized subjects to modified Blalock-Taussig shunt (MBTS) or right ventricle-to-pulmonary artery shunt (RVPAS) for the Norwood procedure, demonstrated RVPAS was associated with smaller pulmonary artery diameter, but superior 12-month transplant-free survival. Methods We analyzed pre-stage II catheterization data for SVR trial subjects. Hemodynamic variables and shunt and pulmonary angiography were compared between shunt types; their association with 12-month transplant-free survival was also evaluated. Results Of 549 randomized subjects, 389 underwent pre-stage II catheterization. Smaller size, lower aortic and superior vena cava saturation, and higher ventricular end-diastolic pressure (EDP) were associated with worse 12-month transplant-free survival. MBTS subjects had lower coronary perfusion pressure (27mmHg vs. 32mmHg, P<0.001) and higher Qp:Qs ratio (1.1 vs. 1.0, P=0.009). Higher Qp:Qs ratio increased the risk of death or transplant only in the RVPAS group (P=0.01). MBTS subjects had fewer shunt (14% vs. 28%, P=0.004) and severe left pulmonary artery stenoses (0.7% vs. 9.2%, P=0.003), larger mid-main branch pulmonary artery diameters and higher Nakata index (164 vs. 134, P<0.001). Conclusions Compared with RVPAS subjects, MBTS subjects had more hemodynamic abnormalities related to shunt physiology, while RVPAS subjects had more shunt or pulmonary obstruction of a severe degree, and inferior pulmonary artery growth at pre-stage II catheterization. Lower BSA, higher ventricular EDP, and lower SVC saturation were associated with worse 12-month transplant-free survival.

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Section: Discussioncontrasting

confidence: 99%

Impact of pre–stage II hemodynamics and pulmonary artery anatomy on 12-month outcomes in the Pediatric Heart Network Single Ventricle Reconstruction trial

Aiyagari

Rhodes

Shrader

et al. 2014

The Journal of Thoracic and Cardiovascular Surgery

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“…Following a ventriculotomy, a conduit is inserted between the RV and the main pulmonary artery. This results in volume loading from conduit regurgitation and a scar on the systemic ventricle predisposing the patient to an increased risk of arrhythmias or aneurysmal dilatation of the outflow tract [5]. Recent evidence from a large randomized trial initially showed no differences in echocardiographic measures of RV ejection fraction (EF) at 1 year of age [6].…”

Section: Introductionmentioning

confidence: 99%

Right ventricular morphology and function following stage I palliation with a modified Blalock–Taussig shunt versus a right ventricle-to-pulmonary artery conduit

Wong

Lamata

Rathod

et al. 2016

Eur J Cardiothorac Surg

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OBJECTIVESThe Norwood procedure for hypoplastic left heart syndrome (HLHS) is performed either via a right ventricle-to-pulmonary artery (RVPA) conduit or a modified Blalock–Taussig (MBT) shunt. Cardiac magnetic resonance (CMR) data was used to assess the effects of the RVPA conduit on ventricular shape and function through a computational analysis of anatomy and assessment of indices of strain.METHODSA retrospective analysis of 93 CMR scans of subjects with HLHS was performed (59 with MBT shunt, 34 with RVPA conduit), incorporating data at varying stages of surgery from two congenital centres. Longitudinal and short-axis cine images were used to create a computational cardiac atlas and assess global strain.RESULTSThose receiving an RVPA conduit had significant differences (P< 0.0001) in the shape of the RV corresponding to increased ventricular dilatation (P = 0.001) and increased sphericity (P = 0.006). Differences were evident only following completion of stage II surgery. Despite preserved ejection fraction in both groups, functional strain in the RVPA conduit group compared with that in the MBT shunt group was reduced across multiple ventricular axes, including a reduced systolic longitudinal strain rate (P< 0.0001), reduced diastolic longitudinal strain rate (P = 0.0001) and reduced midventricular systolic circumferential strain (P < 0.0001).CONCLUSIONSComputational modelling analysis reveals differences in ventricular remodelling in patients with HLHS undergoing an RVPA conduit insertion with focal scarring and volume loading leading to decreased functional markers of strain. The need for continued surveillance is warranted, as deleterious effects may not become apparent until later years.

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“…Shunt stenosis at the proximal end, a frequently reported complication of the RV‐PA shunt, cannot be dealt with in this approach. To prevent proximal stenosis, the whole wall myocardium at the ventriculotomy is removed with the coronary punch bioptome, and a large‐diameter anastomosis is created using a 6 mm conduit in patients weighing more than 2,800 g.…”

Section: Discussionmentioning

confidence: 99%

A Left Anterior Extrapleural Approach to Adjust Right Ventricle-Pulmonary Artery Shunt Flow Using Hemostatic Clips After the Norwood Operation

et al. 2015

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Adjusting right ventricle-pulmonary artery shunt flow with placement of hemostatic clips in the Norwood operation is a useful technique for precise control of pulmonary blood flow in the acute postoperative period. This report describes our technique for optimizing right ventricle-pulmonary artery shunt flow with metal clips through a left anterior extrapleural approach, which can be performed safely and minimally invasively without sternal reopening. This procedure may decrease morbidity and contribute to long-term clinical improvement in patients undergoing the Norwood operation.

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Right ventricle-to-pulmonary artery shunt related complications after Norwood procedure☆

Abstract: The RV-PA shunt can be a safe and efficient technique in providing optimal pulmonary blood flow in the children with HLHS after Norwood procedure, performed with minimal rate of complications. In our experience, the use of RV-PA shunt in NP does not require earlier second-stage procedure.

Cited by 8 publications

References 25 publications

Impact of pre–stage II hemodynamics and pulmonary artery anatomy on 12-month outcomes in the Pediatric Heart Network Single Ventricle Reconstruction trial

Impact of pre–stage II hemodynamics and pulmonary artery anatomy on 12-month outcomes in the Pediatric Heart Network Single Ventricle Reconstruction trial

Right ventricular morphology and function following stage I palliation with a modified Blalock–Taussig shunt versus a right ventricle-to-pulmonary artery conduit

A Left Anterior Extrapleural Approach to Adjust Right Ventricle-Pulmonary Artery Shunt Flow Using Hemostatic Clips After the Norwood Operation

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