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DR.V.S.R.BHUPAL
PRESENTATION OVERVIEW 
 Introduction 
 History 
 Indications for Surgery 
 Surgical Technique 
 Postoperative Physiology 
 Postoperative Issues 
GLENN SHUNT-A REVIEW
INTRODUCTION 
 Atresia of an atrioventricular or semilunar valve results in single-ventricle 
anatomies that have complete mixing of the systemic and 
pulmonary venous circulations 
 Structural defects that are generally managed with a staged 
palliation include variations of single left ventricle and variations 
of single right ventricle. 
GLENN SHUNT-A REVIEW
GENERAL PRINCIPLES OF SUPERIOR AND TOTAL 
CAVOPULMONARY CONNECTIONS 
 Goal of surgical palliation in single-ventricle lesions - to 
separate the systemic and pulmonary circuits, resulting in 
normal or near normal oxygen saturation. 
 Cavopulmonary connections -used to divert systemic venous 
return directly into the pulmonary vascular bed, providing more 
“effective” pulmonary blood flow and reducing the volume load 
on the single ventricle. 
GLENN SHUNT-A REVIEW
 After these procedures, the single ventricle ejects blood only to the 
systemic circuit, with pulmonary blood flow derived by “passive 
flow” into the pulmonary vascular bed at the expense of higher 
central venous pressure. 
 Although cavopulmonary connections improve cyanosis and 
minimize ventricular work, the elevated PVR in the neonate 
precludes their use until approximately 3 months of age 
GLENN SHUNT-A REVIEW
 The cavopulmonary connections used to stage the single-ventricle 
patient to the modified Fontan 
1)BDG 
2)Hemi-Fontan. 
 Staging to Fontan performed because of the high incidence of 
pleural effusions and low-output myocardial failure when taken 
directly for fontan procedure.. 
GLENN SHUNT-A REVIEW
Single left ventricle physiologies 
 Tricuspid atresia with normally related great arteries 
 Double-inlet left ventricle with normally related great arteries 
 Transposition of the great arteries with PS 
 Malaligned atrioventricular canal with hypoplastic right ventricle 
 Pulmonary atresia with intact ventricular septum 
GLENN SHUNT-A REVIEW
TRICUSPID ATRESIA 
GLENN SHUNT-A REVIEW
Single right ventricle physiologies 
 Hypoplastic left heart syndrome [HLHS] 
 Double-outlet right ventricle with mitral atresia 
 Malaligned atrioventricular canal with hypoplastic left ventricle 
 Heterotaxy syndromes 
GLENN SHUNT-A REVIEW
HYPOPLASTIC LEFT HEART SYNDROME 
GLENN SHUNT-A REVIEW
GOALS OF STAGE 1 PALLIATION 
Unobstructed systemic blood flow 
Limited pulmonary blood flow 
Undistorted pulmonary arteries 
Unobstructed pulmonary venous return 
Minimal atrioventricular valve regurgitation 
GLENN SHUNT-A REVIEW
 Surgical palliation allows the neonate to survive into infancy but is 
not a stable anatomic or physiologic long-term solution. 
 Children with single-ventricle anatomy will ultimately undergo 
some variation of the Fontan operation as their final surgical 
palliation 
GLENN SHUNT-A REVIEW
Selecting Patients with Tricuspid Atresia for the 
Fontan Procedure: The “Ten Commandments” 
1. Minimum age, 4 years 
2. Sinus rhythm 
3. Normal caval drainage 
4. Right atrium of normal volume 
5. Mean pulmonary artery pressure ≤ 15 mm Hg 
6. Pulmonary arterial resistance < 4 U/m2 
7. Pulmonary-artery-to-aorta-diameter ratio ≥ 0.75 
8. Normal ventricular functions (ejection fraction > 0.6) 
9. Competent left atrioventricular valve 
10. No impairing effects of previous shunts 
GLENN SHUNT-A REVIEW
History 
 In the 1950s and 1960s in Italy, the United States, and Russia, many 
surgeons were concurrently discovering and harnessing the utility 
of the cavopulmonary connection. 
 An experimental model of the cavopulmonary anastomosis was 
used in dogs by Carlon in the 1950s. 
 This model identified many of the hemodynamic and surgical 
advantages of the cavopulmonary anastomosis relative to the 
Blalock-Taussig shunt. 
GLENN SHUNT-A REVIEW
 The first significant clinical use of the cavopulmonary anastomosis 
in the United States was performed by Glenn. 
 He used unidirectional (classic) and bidirectional superior 
cavopulmonary anastomoses and inferior cavopulmonary 
anastomosis (inferior vena cava [IVC]-to-PA connection). 
 Interim palliation with a BDG shunt has now become the standard 
of care over the past decade, typically in infancy (4 to 9 months of 
age). 
GLENN SHUNT-A REVIEW
DR WILLIAM GLENN 
GLENN SHUNT-A REVIEW
GLENN SHUNT-A REVIEW
Timing of shunt 
 With a decrease in PVR, infants with single ventricle who have had a 
neonatal palliation become candidates for the superior 
cavopulmonary anastomoses by 3 to 6 months of age. 
 Mahle and associates showed that early ventricular unloading after 
neonatal single-ventricle palliation improved aerobic exercise 
performance in preadolescents with the Fontan palliation. 
 An additional advantage of an early superior cavopulmonary 
anastomosis is the opportunity to address distorted pulmonary 
arteries from previous bands or shunts and to create a better 
distribution of PA blood flow and growth of the pulmonary vascular 
bed. 
GLENN SHUNT-A REVIEW
Indications for early shunt procedure 
 Cyanosis secondary to inadequate pulmonary blood flow after 
neonatal palliation 
Congestive heart failure from an excessive volume load caused by 
severe atrioventricular valve regurgitation or by an elevated Qp:Qs. 
GLENN SHUNT-A REVIEW
 The benefits of early cavopulmonary anastomosis must be weighed 
against the risks of elevated SVC pressure and cyanosis. 
 Bradley and colleagues found that cavopulmonary anastomosis at 
younger than 3 months was associated with lower oxygen saturation 
in the early postoperative period and a risk of PA thrombosis. 
 Some infants with severe ventricular dysfunction or 
atrioventricular valve regurgitation may not be suitable for further 
staged palliation and may require heart transplantation 
GLENN SHUNT-A REVIEW
Prerequisites before the procedure 
 Echocardiogram 
 Cardiac catheterization 
For anatomic and hemodynamic assessment of the 
 Pulmonary arteries, 
 Aortic arch 
 Ventricular and atrioventricular valve function 
 Caval anatomy-Presence of decompressing veins that may 
result in cyanosis after superior cavopulmonary 
anastomosis. 
GLENN SHUNT-A REVIEW
CLASSIC GLENN SHUNT 
Dr. Glenn described an anastomosis between the transected 
distal end of the right pulmonary artery and the 
side of the SVC, which is ligated distal to the anastomosis. 
The azygous vein is ligated to prevent its 
decompressing flow from the SVC. 
GLENN SHUNT-A REVIEW
BIDIRECTIONAL GLENN SHUNT 
The BDG operation is performed via median 
sternotomy . At the initiation of cardiopulmonary 
bypass (CPB), the shunt is ligated with a vascular clip 
or ligature. Preservation of the proper spatial 
orientation of the SVC relative to the PA is essential. 
Therefore the azygos vein is ligated but not divided. 
The SVC is then divided, and the cardiac end is 
oversewn. The cephalic end is anastomosed end to side 
to the ipsilateral PA. 
GLENN SHUNT-A REVIEW
 As with the classic glenn shunt, the bi-directional cavo-pulmonary shunt 
is far less likely to engender Pulmonary vascular obstructive disease 
compared with systemic-pulmonary shunts, and there is minimal 
Distortion of the pulmonary artery architecture. 
GLENN SHUNT-A REVIEW
Shunt between the Superior Vena Cava and Right Pulmonary Artery — Technic of Anastomosis. 
Glenn WW. N Engl J Med 1958;259:117-120.
Angiogram Taken Two Months after Operation. 
Glenn WW. N Engl J Med 1958;259:117-120.
Arterial Oxygen Studies before and after the Shunt.* 
Glenn WW. N Engl J Med 1958;259:117-120.
Technique Without Cardiopulmonary Bypass 
BDG may be performed without the utilization of CPB. 
 Patients with sources of pulmonary blood flow that do not need 
interruption as part of the cavopulmonary anastomosis (antegrade 
flow through a stenotic pulmonary valve or banded PA) and have no 
specific intracardiac pathology requiring revision are candidates for 
cavopulmonary anastomosis without CPB. 
 HLHS patients are not candidates for superior cavopulmonary 
anastomosis without CPB because their pulmonary blood flow is 
shunt dependent, and because they may require PA reconstruction 
and other intracardiac procedures at the time of their superior 
cavopulmonary anastomosis 
GLENN SHUNT-A REVIEW
HEMI FONTAN PROCEDURE 
GLENN SHUNT-A REVIEW
FONTAN PROCEDURE 
d’Udekem Y et al. Circulation 2007;116:I-157-I-164 
Copyright © American Heart Association, Inc. All rights reserved.
GLENN SHUNT-A REVIEW
GLENN SHUNT-A REVIEW
Postoperative Physiology 
 After completion of the superior cavopulmonary anastomosis, the 
circulation to the lungs is from the upper body systemic venous 
return. 
 The pulmonary blood flow results from upper body blood flow,all 
SVC return must pass through the lungs to reach the heart in the 
absence of decompressing venous collaterals. 
GLENN SHUNT-A REVIEW
 The principal physiologic advantage of conversion to a superior 
cavopulmonary anastomosis at an early age is the reduction of the 
volume work of the single ventricle and a predictable Qp:Qs of 
approximately 0.6 to 0.7. 
 This ratio is higher in young infants because of the relative size of 
the head and the upper extremities in young infants as opposed to 
those in older children, but in general, systemic arterial oxygen 
saturations (SaO2) are 75% to 85%. 
GLENN SHUNT-A REVIEW
 The immediate reduction in the volume load of the single ventricle 
by removing the aortopulmonary shunt decreases the work of the 
single ventricle and may improve long-term atrio-ventricular valve 
and myocardial function. 
 Atrioventricular valve regurgitation resulting from physiologic 
rather than structural abnormalities may decrease as the 
ventricular geometry normalizes 
GLENN SHUNT-A REVIEW
 After superior cavopulmonary anastomosis, oxygen is delivered 
more efficiently to the body because only deoxygenated blood from 
the SVC rather than admixed blood from the ventricle is presented 
to the lungs for oxygen uptake. 
 The net result of the more efficient oxygen uptake in the lungs is a 
reduction in cardiac output needed to achieve a given tissue O2 
delivery 
GLENN SHUNT-A REVIEW
DIASTOLIC DYSFUNCTION 
GLENN SHUNT-A REVIEW
 After the BDG or hemi-Fontan, ventricular filling is not absolutely 
dependent on pulmonary venous return, because IVC flow is still 
diverted directly to the single ventricle and maintains preload. 
 As a result, the acute volume reduction noted after superior 
cavopulmonary anastomosis is better tolerated than in the case of 
transitioning a child from a neonatal palliation directly to the 
Fontan completion without an intervening superior cavopulmonary 
anastomosis 
GLENN SHUNT-A REVIEW
 SaO2 after creation of a BDG shunt tends to be lower in very young 
younger than 3 months patients. 
 Although some patients as young as 4 weeks have had satisfactory BDG 
shunt creation, patients younger than 3 months have a higher incidence 
of early cyanosis, PA thrombosis, and vascular congestion. 
 Therefore a delay of the procedure until the child is older than 3 months 
is generally recommended. 
 By age 6 months, the mortality risk approaches 0 in many centers. 
GLENN SHUNT-A REVIEW
Postoperative Issues 
GLENN SHUNT-A REVIEW
Mechanical Ventilation 
 Positive pressure ventilation with increased mean airway pressures 
adversely affects PVR and ventricular filling 
 Early institution of spontaneous ventilation improves 
hemodynamics in the awake patient. 
 Spontaneous breathing also increases pco2, which will promote 
increased cerebral blood flow and, thereby, increase pulmonary 
blood flow. 
GLENN SHUNT-A REVIEW
 “Physiologic” (3 to 5 cm H2O) positive end-expiratory pressure 
(PEEP) is generally well tolerated, does not significantly affect PVR 
or cardiac output, and may improve oxygenation by reducing areas 
of microatelectasis, reestablishing functional residual capacity, and 
improving ventilation/–perfusion matching. 
GLENN SHUNT-A REVIEW
Elevated Cavopulmonary Pressures 
 The goal of postoperative cavopulmonary anastomosis management is 
to minimize the transpulmonary gradient (PA mean pressure – 
common atrium mean pressure) to allow passive pulmonary blood 
flow through the lungs and back to the single ventricle. 
 An elevated transpulmonary gradient may result from pulmonary 
venous obstruction, elevated PVR, or pleural effusion, hemothorax, or 
pneumothorax. 
 Extubating the patient expeditiously will reduce the common atrial 
pressure and promote flow through the lungs by creating a greater 
transthoracic gradient from the extrathoracic space to the 
intrathoracic space. 
 Diminished cavopulmonary blood flow will reduce systemic SaO2 
GLENN SHUNT-A REVIEW
 Elevation of PVR from the inflammatory effects of CPB may be 
minimized with pulmonary vasodilators such as nitric oxide at 5 
to 20 parts per million in inspired gas. 
 Mild facial edema after superior cavopulmonary anastomosis 
may persist for up to 72 hours. 
 Majority of pleural effusions after superior cavopulmonary 
anastomosis will diminish over time with judicious diuretic use 
and fluid restriction. 
GLENN SHUNT-A REVIEW
 Patients are typically given aspirin (5 mg/kg/day) after superior 
cavopulmonary anastomosis to reduce the risk of thrombosis of 
the superior cavopulmonary circuit 
GLENN SHUNT-A REVIEW
 Patients with clinical signs of significantly elevated SVC pressure 
,upper extremity plethora and edema may have obstruction at the 
cavopulmonary anastomosis, distal PA distortion, or marked 
elevations in PVR. 
 Significant elevations of pressure in the SVC may limit cerebral 
blood flow. 
 If the SVC pressure is more than 18 mm Hg, the etiology should be 
promptly investigated, including early catheterization, if necessary 
GLENN SHUNT-A REVIEW
Hypertension and Bradycardia 
 Transient postoperative hypertension and bradycardia have been 
frequently observed in the first 24 to 72 hours after the 
cavopulmonary shunt. 
 Hypertension may be due to pain, catecholamine secretion, 
intracranial hypertension, or a combination of these. 
 The acute elevation of the central venous pressure may result in 
a reflex similar to that seen in head trauma, such that systemic 
hypertension is necessary to preserve adequate cerebral 
perfusion. 
 Therefore aggressive lowering of the blood pressure may 
adversely affect the cerebral perfusion pressure, and vasodilators 
should be used cautiously. 
GLENN SHUNT-A REVIEW
 Transient bradycardia is typically seen after a cavopulmonary 
connection and may be due to the acute reduction of the volume 
load of the single ventricle, or may be due to injury to the sinus 
node or its arterial supply. 
GLENN SHUNT-A REVIEW
Low Cardiac Output 
 When the child has preexisting ventricular dysfunction or severe 
atrio-ventricular valve regurgitation. 
 In these volume-loaded ventricles, which need high filling 
pressures to generate adequate output, volume reduction and the 
effects from CPB may significantly reduce cardiac output and 
oxygen delivery to the tissues. 
GLENN SHUNT-A REVIEW
Cyanosis 
 Excessive hypoxemia (SpO2 <75%) should be investigated promptly. 
 The differential diagnosis of excessive or unexplained cyanosis can 
be grouped into three broad categories: pulmonary venous 
desaturation, systemic venous desaturation, or decreased 
pulmonary blood flow. 
GLENN SHUNT-A REVIEW
Pulmonary venous desaturation 
 Pleural effusion 
 Pneumothorax 
 Hemothorax 
 Chylothorax 
 Pulmonary edema 
 Atelectasis 
 Bacterial pneumonia/viral pneumonitis 
 Arteriovenous malformation 
GLENN SHUNT-A REVIEW
Systemic venous desaturation/Decreased 
oxygen delivery 
 Anemia 
 Low cardiac output 
 Decreased ventricular function 
 Severe atrioventricular valve regurgitation 
 Pericardial tamponade 
GLENN SHUNT-A REVIEW
Increased oxygen consumption 
 Sepsis 
 Venovenous collateral from superior cavopulmonary circuit via the 
systemic venous circuit to the systemic ventricle 
 Baffle leak 
GLENN SHUNT-A REVIEW
Decreased pulmonary blood flow 
 Pulmonary venous hypertension 
 Restrictive atrial communication 
 Decompressing vein 
GLENN SHUNT-A REVIEW
 Decreased pulmonary blood flow may be due to decompressing 
venovenous collaterals, an undiagnosed contralateral (usually left) 
SVC. 
 Factors related to the development of decompressing venous 
collaterals include bilateral superior vena cava, a higher early 
postoperative transpulmonary gradient, and elevated pressure in 
the SVC. 
GLENN SHUNT-A REVIEW
 A left SVC to coronary sinus, which appeared closed on the cardiac 
catheterization before the superior cavopulmonary anastomosis, 
may re-canalize, resulting in significant desaturation after superior 
cavopulmonary anastomosis. 
 Successful transcatheter coil embolization of these vessels can be 
accomplished with good results 
GLENN SHUNT-A REVIEW
PULMONARY AV MALFORMATIONS 
 A cause of pulmonary venous desaturation after a BDG is the 
development of pulmonary arteriovenous malformations, 
particularly in patients with heterotaxy syndrome. 
 Diversion of normal hepatic venous flow from the pulmonary 
circulation may be related to development of these abnormal 
pathways,and some have been noted to regress after 
incorporation of hepatic venous flow into the lungs. 
 Pulmonary arteriovenous malformations have been associated 
with young age at the time of the superior cavopulmonary 
anastomosis, polysplenia (interrupted IVC with azygos 
continuation to the SVC). 
GLENN SHUNT-A REVIEW
 Pulmonary arteriovenous malformations typically cause gradual 
hypoxemia months to years after the surgical procedure, rather 
than in the immediate postoperative period. 
 Studies have shown that a pulsatile second source of pulmonary 
blood flow may minimize the development of pulmonary 
arteriovenous malformations. 
 In most cases, the malformations diminish or disappear 
completely after fontan completion. 
 Although theoretic advantages exist to an ivc-pa cavopulmonary 
anastomosis relative to the formation of pulmonary 
arteriovenous malformations, the elevation in hepatic venous 
pressure and the detrimental effects on liver function may be 
prohibitive GLENN SHUNT-A REVIEW
 Song and colleagues reported that long-term aspirin (a 
cyclooxygenase inhibitor) therapy has successfully prevented the 
development of cyanosis, possibly by preventing pulmonary AV 
fistula formation. 
 Transcatheterembolisationwhen feeding artery greater than 3mm. 
 Surgery-Fistulectomy/Lobectomy 
GLENN SHUNT-A REVIEW
THANK YOU 
GLENN SHUNT-A REVIEW

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Glenn shunt a review

  • 2. PRESENTATION OVERVIEW  Introduction  History  Indications for Surgery  Surgical Technique  Postoperative Physiology  Postoperative Issues GLENN SHUNT-A REVIEW
  • 3. INTRODUCTION  Atresia of an atrioventricular or semilunar valve results in single-ventricle anatomies that have complete mixing of the systemic and pulmonary venous circulations  Structural defects that are generally managed with a staged palliation include variations of single left ventricle and variations of single right ventricle. GLENN SHUNT-A REVIEW
  • 4. GENERAL PRINCIPLES OF SUPERIOR AND TOTAL CAVOPULMONARY CONNECTIONS  Goal of surgical palliation in single-ventricle lesions - to separate the systemic and pulmonary circuits, resulting in normal or near normal oxygen saturation.  Cavopulmonary connections -used to divert systemic venous return directly into the pulmonary vascular bed, providing more “effective” pulmonary blood flow and reducing the volume load on the single ventricle. GLENN SHUNT-A REVIEW
  • 5.  After these procedures, the single ventricle ejects blood only to the systemic circuit, with pulmonary blood flow derived by “passive flow” into the pulmonary vascular bed at the expense of higher central venous pressure.  Although cavopulmonary connections improve cyanosis and minimize ventricular work, the elevated PVR in the neonate precludes their use until approximately 3 months of age GLENN SHUNT-A REVIEW
  • 6.  The cavopulmonary connections used to stage the single-ventricle patient to the modified Fontan 1)BDG 2)Hemi-Fontan.  Staging to Fontan performed because of the high incidence of pleural effusions and low-output myocardial failure when taken directly for fontan procedure.. GLENN SHUNT-A REVIEW
  • 7. Single left ventricle physiologies  Tricuspid atresia with normally related great arteries  Double-inlet left ventricle with normally related great arteries  Transposition of the great arteries with PS  Malaligned atrioventricular canal with hypoplastic right ventricle  Pulmonary atresia with intact ventricular septum GLENN SHUNT-A REVIEW
  • 8. TRICUSPID ATRESIA GLENN SHUNT-A REVIEW
  • 9. Single right ventricle physiologies  Hypoplastic left heart syndrome [HLHS]  Double-outlet right ventricle with mitral atresia  Malaligned atrioventricular canal with hypoplastic left ventricle  Heterotaxy syndromes GLENN SHUNT-A REVIEW
  • 10. HYPOPLASTIC LEFT HEART SYNDROME GLENN SHUNT-A REVIEW
  • 11. GOALS OF STAGE 1 PALLIATION Unobstructed systemic blood flow Limited pulmonary blood flow Undistorted pulmonary arteries Unobstructed pulmonary venous return Minimal atrioventricular valve regurgitation GLENN SHUNT-A REVIEW
  • 12.  Surgical palliation allows the neonate to survive into infancy but is not a stable anatomic or physiologic long-term solution.  Children with single-ventricle anatomy will ultimately undergo some variation of the Fontan operation as their final surgical palliation GLENN SHUNT-A REVIEW
  • 13. Selecting Patients with Tricuspid Atresia for the Fontan Procedure: The “Ten Commandments” 1. Minimum age, 4 years 2. Sinus rhythm 3. Normal caval drainage 4. Right atrium of normal volume 5. Mean pulmonary artery pressure ≤ 15 mm Hg 6. Pulmonary arterial resistance < 4 U/m2 7. Pulmonary-artery-to-aorta-diameter ratio ≥ 0.75 8. Normal ventricular functions (ejection fraction > 0.6) 9. Competent left atrioventricular valve 10. No impairing effects of previous shunts GLENN SHUNT-A REVIEW
  • 14. History  In the 1950s and 1960s in Italy, the United States, and Russia, many surgeons were concurrently discovering and harnessing the utility of the cavopulmonary connection.  An experimental model of the cavopulmonary anastomosis was used in dogs by Carlon in the 1950s.  This model identified many of the hemodynamic and surgical advantages of the cavopulmonary anastomosis relative to the Blalock-Taussig shunt. GLENN SHUNT-A REVIEW
  • 15.  The first significant clinical use of the cavopulmonary anastomosis in the United States was performed by Glenn.  He used unidirectional (classic) and bidirectional superior cavopulmonary anastomoses and inferior cavopulmonary anastomosis (inferior vena cava [IVC]-to-PA connection).  Interim palliation with a BDG shunt has now become the standard of care over the past decade, typically in infancy (4 to 9 months of age). GLENN SHUNT-A REVIEW
  • 16. DR WILLIAM GLENN GLENN SHUNT-A REVIEW
  • 18. Timing of shunt  With a decrease in PVR, infants with single ventricle who have had a neonatal palliation become candidates for the superior cavopulmonary anastomoses by 3 to 6 months of age.  Mahle and associates showed that early ventricular unloading after neonatal single-ventricle palliation improved aerobic exercise performance in preadolescents with the Fontan palliation.  An additional advantage of an early superior cavopulmonary anastomosis is the opportunity to address distorted pulmonary arteries from previous bands or shunts and to create a better distribution of PA blood flow and growth of the pulmonary vascular bed. GLENN SHUNT-A REVIEW
  • 19. Indications for early shunt procedure  Cyanosis secondary to inadequate pulmonary blood flow after neonatal palliation Congestive heart failure from an excessive volume load caused by severe atrioventricular valve regurgitation or by an elevated Qp:Qs. GLENN SHUNT-A REVIEW
  • 20.  The benefits of early cavopulmonary anastomosis must be weighed against the risks of elevated SVC pressure and cyanosis.  Bradley and colleagues found that cavopulmonary anastomosis at younger than 3 months was associated with lower oxygen saturation in the early postoperative period and a risk of PA thrombosis.  Some infants with severe ventricular dysfunction or atrioventricular valve regurgitation may not be suitable for further staged palliation and may require heart transplantation GLENN SHUNT-A REVIEW
  • 21. Prerequisites before the procedure  Echocardiogram  Cardiac catheterization For anatomic and hemodynamic assessment of the  Pulmonary arteries,  Aortic arch  Ventricular and atrioventricular valve function  Caval anatomy-Presence of decompressing veins that may result in cyanosis after superior cavopulmonary anastomosis. GLENN SHUNT-A REVIEW
  • 22. CLASSIC GLENN SHUNT Dr. Glenn described an anastomosis between the transected distal end of the right pulmonary artery and the side of the SVC, which is ligated distal to the anastomosis. The azygous vein is ligated to prevent its decompressing flow from the SVC. GLENN SHUNT-A REVIEW
  • 23. BIDIRECTIONAL GLENN SHUNT The BDG operation is performed via median sternotomy . At the initiation of cardiopulmonary bypass (CPB), the shunt is ligated with a vascular clip or ligature. Preservation of the proper spatial orientation of the SVC relative to the PA is essential. Therefore the azygos vein is ligated but not divided. The SVC is then divided, and the cardiac end is oversewn. The cephalic end is anastomosed end to side to the ipsilateral PA. GLENN SHUNT-A REVIEW
  • 24.  As with the classic glenn shunt, the bi-directional cavo-pulmonary shunt is far less likely to engender Pulmonary vascular obstructive disease compared with systemic-pulmonary shunts, and there is minimal Distortion of the pulmonary artery architecture. GLENN SHUNT-A REVIEW
  • 25. Shunt between the Superior Vena Cava and Right Pulmonary Artery — Technic of Anastomosis. Glenn WW. N Engl J Med 1958;259:117-120.
  • 26. Angiogram Taken Two Months after Operation. Glenn WW. N Engl J Med 1958;259:117-120.
  • 27. Arterial Oxygen Studies before and after the Shunt.* Glenn WW. N Engl J Med 1958;259:117-120.
  • 28. Technique Without Cardiopulmonary Bypass BDG may be performed without the utilization of CPB.  Patients with sources of pulmonary blood flow that do not need interruption as part of the cavopulmonary anastomosis (antegrade flow through a stenotic pulmonary valve or banded PA) and have no specific intracardiac pathology requiring revision are candidates for cavopulmonary anastomosis without CPB.  HLHS patients are not candidates for superior cavopulmonary anastomosis without CPB because their pulmonary blood flow is shunt dependent, and because they may require PA reconstruction and other intracardiac procedures at the time of their superior cavopulmonary anastomosis GLENN SHUNT-A REVIEW
  • 29. HEMI FONTAN PROCEDURE GLENN SHUNT-A REVIEW
  • 30. FONTAN PROCEDURE d’Udekem Y et al. Circulation 2007;116:I-157-I-164 Copyright © American Heart Association, Inc. All rights reserved.
  • 33. Postoperative Physiology  After completion of the superior cavopulmonary anastomosis, the circulation to the lungs is from the upper body systemic venous return.  The pulmonary blood flow results from upper body blood flow,all SVC return must pass through the lungs to reach the heart in the absence of decompressing venous collaterals. GLENN SHUNT-A REVIEW
  • 34.  The principal physiologic advantage of conversion to a superior cavopulmonary anastomosis at an early age is the reduction of the volume work of the single ventricle and a predictable Qp:Qs of approximately 0.6 to 0.7.  This ratio is higher in young infants because of the relative size of the head and the upper extremities in young infants as opposed to those in older children, but in general, systemic arterial oxygen saturations (SaO2) are 75% to 85%. GLENN SHUNT-A REVIEW
  • 35.  The immediate reduction in the volume load of the single ventricle by removing the aortopulmonary shunt decreases the work of the single ventricle and may improve long-term atrio-ventricular valve and myocardial function.  Atrioventricular valve regurgitation resulting from physiologic rather than structural abnormalities may decrease as the ventricular geometry normalizes GLENN SHUNT-A REVIEW
  • 36.  After superior cavopulmonary anastomosis, oxygen is delivered more efficiently to the body because only deoxygenated blood from the SVC rather than admixed blood from the ventricle is presented to the lungs for oxygen uptake.  The net result of the more efficient oxygen uptake in the lungs is a reduction in cardiac output needed to achieve a given tissue O2 delivery GLENN SHUNT-A REVIEW
  • 37. DIASTOLIC DYSFUNCTION GLENN SHUNT-A REVIEW
  • 38.  After the BDG or hemi-Fontan, ventricular filling is not absolutely dependent on pulmonary venous return, because IVC flow is still diverted directly to the single ventricle and maintains preload.  As a result, the acute volume reduction noted after superior cavopulmonary anastomosis is better tolerated than in the case of transitioning a child from a neonatal palliation directly to the Fontan completion without an intervening superior cavopulmonary anastomosis GLENN SHUNT-A REVIEW
  • 39.  SaO2 after creation of a BDG shunt tends to be lower in very young younger than 3 months patients.  Although some patients as young as 4 weeks have had satisfactory BDG shunt creation, patients younger than 3 months have a higher incidence of early cyanosis, PA thrombosis, and vascular congestion.  Therefore a delay of the procedure until the child is older than 3 months is generally recommended.  By age 6 months, the mortality risk approaches 0 in many centers. GLENN SHUNT-A REVIEW
  • 40. Postoperative Issues GLENN SHUNT-A REVIEW
  • 41. Mechanical Ventilation  Positive pressure ventilation with increased mean airway pressures adversely affects PVR and ventricular filling  Early institution of spontaneous ventilation improves hemodynamics in the awake patient.  Spontaneous breathing also increases pco2, which will promote increased cerebral blood flow and, thereby, increase pulmonary blood flow. GLENN SHUNT-A REVIEW
  • 42.  “Physiologic” (3 to 5 cm H2O) positive end-expiratory pressure (PEEP) is generally well tolerated, does not significantly affect PVR or cardiac output, and may improve oxygenation by reducing areas of microatelectasis, reestablishing functional residual capacity, and improving ventilation/–perfusion matching. GLENN SHUNT-A REVIEW
  • 43. Elevated Cavopulmonary Pressures  The goal of postoperative cavopulmonary anastomosis management is to minimize the transpulmonary gradient (PA mean pressure – common atrium mean pressure) to allow passive pulmonary blood flow through the lungs and back to the single ventricle.  An elevated transpulmonary gradient may result from pulmonary venous obstruction, elevated PVR, or pleural effusion, hemothorax, or pneumothorax.  Extubating the patient expeditiously will reduce the common atrial pressure and promote flow through the lungs by creating a greater transthoracic gradient from the extrathoracic space to the intrathoracic space.  Diminished cavopulmonary blood flow will reduce systemic SaO2 GLENN SHUNT-A REVIEW
  • 44.  Elevation of PVR from the inflammatory effects of CPB may be minimized with pulmonary vasodilators such as nitric oxide at 5 to 20 parts per million in inspired gas.  Mild facial edema after superior cavopulmonary anastomosis may persist for up to 72 hours.  Majority of pleural effusions after superior cavopulmonary anastomosis will diminish over time with judicious diuretic use and fluid restriction. GLENN SHUNT-A REVIEW
  • 45.  Patients are typically given aspirin (5 mg/kg/day) after superior cavopulmonary anastomosis to reduce the risk of thrombosis of the superior cavopulmonary circuit GLENN SHUNT-A REVIEW
  • 46.  Patients with clinical signs of significantly elevated SVC pressure ,upper extremity plethora and edema may have obstruction at the cavopulmonary anastomosis, distal PA distortion, or marked elevations in PVR.  Significant elevations of pressure in the SVC may limit cerebral blood flow.  If the SVC pressure is more than 18 mm Hg, the etiology should be promptly investigated, including early catheterization, if necessary GLENN SHUNT-A REVIEW
  • 47. Hypertension and Bradycardia  Transient postoperative hypertension and bradycardia have been frequently observed in the first 24 to 72 hours after the cavopulmonary shunt.  Hypertension may be due to pain, catecholamine secretion, intracranial hypertension, or a combination of these.  The acute elevation of the central venous pressure may result in a reflex similar to that seen in head trauma, such that systemic hypertension is necessary to preserve adequate cerebral perfusion.  Therefore aggressive lowering of the blood pressure may adversely affect the cerebral perfusion pressure, and vasodilators should be used cautiously. GLENN SHUNT-A REVIEW
  • 48.  Transient bradycardia is typically seen after a cavopulmonary connection and may be due to the acute reduction of the volume load of the single ventricle, or may be due to injury to the sinus node or its arterial supply. GLENN SHUNT-A REVIEW
  • 49. Low Cardiac Output  When the child has preexisting ventricular dysfunction or severe atrio-ventricular valve regurgitation.  In these volume-loaded ventricles, which need high filling pressures to generate adequate output, volume reduction and the effects from CPB may significantly reduce cardiac output and oxygen delivery to the tissues. GLENN SHUNT-A REVIEW
  • 50. Cyanosis  Excessive hypoxemia (SpO2 <75%) should be investigated promptly.  The differential diagnosis of excessive or unexplained cyanosis can be grouped into three broad categories: pulmonary venous desaturation, systemic venous desaturation, or decreased pulmonary blood flow. GLENN SHUNT-A REVIEW
  • 51. Pulmonary venous desaturation  Pleural effusion  Pneumothorax  Hemothorax  Chylothorax  Pulmonary edema  Atelectasis  Bacterial pneumonia/viral pneumonitis  Arteriovenous malformation GLENN SHUNT-A REVIEW
  • 52. Systemic venous desaturation/Decreased oxygen delivery  Anemia  Low cardiac output  Decreased ventricular function  Severe atrioventricular valve regurgitation  Pericardial tamponade GLENN SHUNT-A REVIEW
  • 53. Increased oxygen consumption  Sepsis  Venovenous collateral from superior cavopulmonary circuit via the systemic venous circuit to the systemic ventricle  Baffle leak GLENN SHUNT-A REVIEW
  • 54. Decreased pulmonary blood flow  Pulmonary venous hypertension  Restrictive atrial communication  Decompressing vein GLENN SHUNT-A REVIEW
  • 55.  Decreased pulmonary blood flow may be due to decompressing venovenous collaterals, an undiagnosed contralateral (usually left) SVC.  Factors related to the development of decompressing venous collaterals include bilateral superior vena cava, a higher early postoperative transpulmonary gradient, and elevated pressure in the SVC. GLENN SHUNT-A REVIEW
  • 56.  A left SVC to coronary sinus, which appeared closed on the cardiac catheterization before the superior cavopulmonary anastomosis, may re-canalize, resulting in significant desaturation after superior cavopulmonary anastomosis.  Successful transcatheter coil embolization of these vessels can be accomplished with good results GLENN SHUNT-A REVIEW
  • 57. PULMONARY AV MALFORMATIONS  A cause of pulmonary venous desaturation after a BDG is the development of pulmonary arteriovenous malformations, particularly in patients with heterotaxy syndrome.  Diversion of normal hepatic venous flow from the pulmonary circulation may be related to development of these abnormal pathways,and some have been noted to regress after incorporation of hepatic venous flow into the lungs.  Pulmonary arteriovenous malformations have been associated with young age at the time of the superior cavopulmonary anastomosis, polysplenia (interrupted IVC with azygos continuation to the SVC). GLENN SHUNT-A REVIEW
  • 58.  Pulmonary arteriovenous malformations typically cause gradual hypoxemia months to years after the surgical procedure, rather than in the immediate postoperative period.  Studies have shown that a pulsatile second source of pulmonary blood flow may minimize the development of pulmonary arteriovenous malformations.  In most cases, the malformations diminish or disappear completely after fontan completion.  Although theoretic advantages exist to an ivc-pa cavopulmonary anastomosis relative to the formation of pulmonary arteriovenous malformations, the elevation in hepatic venous pressure and the detrimental effects on liver function may be prohibitive GLENN SHUNT-A REVIEW
  • 59.  Song and colleagues reported that long-term aspirin (a cyclooxygenase inhibitor) therapy has successfully prevented the development of cyanosis, possibly by preventing pulmonary AV fistula formation.  Transcatheterembolisationwhen feeding artery greater than 3mm.  Surgery-Fistulectomy/Lobectomy GLENN SHUNT-A REVIEW
  • 60. THANK YOU GLENN SHUNT-A REVIEW