European Journal of Cardio-Thoracic Surgery, Vol 12, 177-183, Copyright © 1997 by European Association for Cardio-thoracic Surgery
Bidirectional Glenn followed by total cavopulmonary connection or primary total cavopulmonary connection?
M Kostelka, B Hucin, T Tlaskal, V Chaloupecky, O Reich, J Janousek, J Marek and J Skovranek
Kardiocentrum, University Hospital Motol, Prague, Czech Republic. martin.kostelka@lfmotol.cuni.cz
OBJECTIVE: Analysis of mortality and morbidity of patients treated by
primary total cavopulmonary connection (TCPC)-Primary correction group, and
comparison to patients treated by bidirectional Glenn (BDG) followed by
total cavopulmonary connection-two stage TCPC group. METHODS: Retrospective
study of 123 consecutive patients who underwent 144 different types of
cavopulmonary connections between 1987-1995: bidirectional Glenn 59,
HemiFontan operation 10, primary total cavopulmonary connection 54, and
total cavopulmonary connection completion after previous bidirectional
Glenn 21. Important preoperative risk factors: age, systemic outflow
obstruction, pulmonary venous obstruction, pulmonary artery (PA) hypoplasia
(McGoon ratio), PA stenosis/distortion, PA mean pressure, PA vascular
resistance, atrioventricular valve regurgitation, systolic and diastolic
ventricular function and ventricular hypertrophy were re-evaluated
according to Texas Heart Institution Scoring System in both groups. Three
different preoperative risk groups were established: low risk, score (0-3)
moderate risk (4,5) and high risk score (> or = 6). RESULTS: Mean age
was 85.2 month (range 16.1-229.5 months) and 106.6 months (range 42.6-178.9
months) in primary correction group and two stage TCPC group, respectively.
Diagnosis was similar in both groups, majority having univentricular heart
or hypoplastic one ventricle. Initial palliation (pulmonary artery banding,
modified aortopulmonary shunt, coarctation repair etc.) was performed in 38
(70.3%) patients of primary correction group and in 12 (57.1%) two stage
TCPC group. The mortality was 7.4% (4 out of 54) and 14.2% (3 out of 21)
for primary correction and two stage TCPC group, respectively. There were
two take down in the primary correction group. There was no late death in
either group. Operative data and postoperative morbidity did not
statistically differ in both groups. CONCLUSION: Until 1993 bidirectional
Glenn was preferred to primary total cavopulmonary connection for high risk
patients. High mortality 14.2% patients of two stage TCPC group vs. 7.4% of
primary correction group in patients with the same preoperative hazard led
us to change our policy. We now prefer primary TCPC for all patients with
functional single ventricle and surgically correctable major associated
defects. High risk patients undergo TCPC with fenestration. Patients not
suitable for TCPC undergo either HemiFontan operation or some type of
initial palliative procedure.
