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J Thorac Cardiovasc Surg. 2017 Feb;153(2):441-447. doi: 10.1016/j.jtcvs.2016.09.048. Epub 2016 Sep 28.

Mechanically assisted bidirectional cavopulmonary shunt in neonates and infants: An acute human pilot study.

Author information

1
The Labatt Family Heart Centre, The Hospital for Sick Children and The University of Toronto, Toronto, Ontario, Canada.
2
Department of Critical Care Medicine, The Hospital for Sick Children and The University of Toronto, Toronto, Ontario, Canada.
3
Department of Anaesthesia, The Hospital for Sick Children and The University of Toronto, Toronto, Ontario, Canada.
4
Division of Cardiovascular Surgery, The Hospital for Sick Children and The University of Toronto, Toronto, Ontario, Canada. Electronic address: glen.vanarsdell@sickkids.ca.

Abstract

OBJECTIVE:

Poor survival following surgical palliation for hypoplastic left heart syndrome (HLHS) raises the question of the need for a paradigm shift. This is the first human study to investigate the possibility of primary "in-series" palliation in neonates and infants with HLHS in an acute setting with the aid of 2 types of mechanical assist: superior vena cava (SVC)-to-pulmonary artery (PA) pump assist and SVC-to-right atrium (RA) oxygenation assist.

METHODS:

By rearranging the cannula sites and flow rates for modified ultrafiltration, 2 types of mechanically assisted bidirectional cavopulmonary shunt (BCPS) circulation were simulated for 20 minutes. Three neonates undergoing a stage I Norwood procedure were assigned to SVC-PA pump assist, and 3 infants undergoing stage II BCPS were assigned to SVC-RA oxygenation assist. Hemodynamic parameters, blood gas values, and arterial (SaO2) and regional cerebral tissue (rCTO2) saturations were analyzed.

RESULTS:

All 6 patients completed the study without hemodynamic compromise. In the SVC-PA pump assist group, a mean arterial pressure >40 mm Hg was maintained. SVC pressure was lower (P = .01) and cerebral perfusion pressure (CPP) was higher (P = .03) during the last 10 minutes of assist compared with Norwood physiology. SaO2 >80%, rCTO2 >60%, and mixed venous saturation ≥59% were maintained, comparable to values with Norwood physiology. In the SVC-RA oxygenation assist group, with full or 50% support, mean blood pressure >50 mm Hg, SVC pressure <15 mm Hg, mixed venous saturation >50%, and CPP >40 mm Hg were maintained, which were comparable to BCPS physiology.

CONCLUSIONS:

Two types of mechanical assist to support primary in-series palliation are feasible in the acute setting. Both modes of mechanical assist maintained oxygenation, as well as systemic and cerebral perfusion.

KEYWORDS:

bidirectional cavopulmonary shunt; in-series palliation; mechanical circulatory assist; single-ventricle physiology

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