Surgical pulmonary arterioplasty at bidirectional cavopulmonary anastomosis leads to favorable pulmonary hemodynamics at final stage palliation

Anna Olds; W Hampton Gray; Markian Bojko; Carly Weaver; John D Cleveland; Michael E Bowdish; Winfield J Wells; Vaughn A Starnes; S Ram Kumar

doi:10.1016/j.xjon.2024.02.006

Surgical pulmonary arterioplasty at bidirectional cavopulmonary anastomosis leads to favorable pulmonary hemodynamics at final stage palliation

JTCVS Open. 2024 Feb 17:18:180-192. doi: 10.1016/j.xjon.2024.02.006. eCollection 2024 Apr.

Authors

Anna Olds^{1

2}, W Hampton Gray^{1

2}, Markian Bojko^{1

2}, Carly Weaver², John D Cleveland^{1

2}, Michael E Bowdish¹, Winfield J Wells^{1

2}, Vaughn A Starnes^{1

2}, S Ram Kumar^{1

2

3}

Affiliations

¹ Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif.
² Division of Cardiac Surgery, Heart Institute, Children's Hospital of Los Angeles, Los Angeles, Calif.
³ Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, Calif.

Abstract

Objective: Pulmonary arterioplasty (PA plasty) at bidirectional cavopulmonary anastomosis (BDCA) is associated with increased morbidity, but outcomes to final stage palliation are unknown. We sought to determine the influence of PA plasty on pulmonary artery growth and hemodyamics at Fontan.

Methods: We retrospectively reviewed clinical data and outcomes for BDCA patients from 2006 to 2018. PA plasty was categorized by extent (type 1-4), as previously described. Outcomes included pulmonary artery reintervention and mortality before final palliation.

Results: Five hundred eighty-eight patients underwent BDCA. One hundred seventy-nine patients (30.0%) underwent concomitant PA plasty. Five hundred seventy (97%) patients (169 [94%] PA plasty) survived to BDCA discharge. One hundred forty out of 570 survivors (25%) required PA/Glenn reintervention before final stage palliation (59 out of 169 [35%]) PA plasty; 81 out of 401 (20%) non-PA plasty; P < .001). Twelve-, 24-, and 36-month freedom from reintervention after BDCA was 80% (95% CI, 74-86%), 75% (95% CI, 69-82%), and 64% (95% CI, 57-73%) for PA plasty, and 95% (95% CI, 93-97%), 91% (95% CI, 88-94%), and 81% (95% CI, 76-85%) for non-PA plasty (P < .001). Prefinal stage mortality was 37 (6.3%) (14 out of 169 PA plasty; 23 out of 401 non-PA plasty; P = .4). Five hundred four (144 PA plasty and 360 non-PA plasty) patients reached final stage palliation (471 Fontan, 26 1.5-ventricle, and 7 2-ventricular repair). Pre-Fontan PA pressure and pulmonary vascular resistance were 10 mm Hg (range, 9-12 mm Hg) and 1.6 mm Hg (range, 1.3-1.9 mm Hg) in PA plasty and 10 mm Hg (range, 8-12 mm Hg) and 1.5 mm Hg (range, 1.3-1.9 mm Hg) in non-PA plasty patients, respectively (P = .29, .6). Fontan hospital mortality, length of stay, and morbidity were similar.

Conclusions: PA plasty at BDCA does not confer additional mortality risk leading to final palliation. Despite increased pulmonary artery reintervention, there was reliable pulmonary artery growth and favorable pulmonary hemodynamics at final stage palliation.

Keywords: Fontan; bidirectional cavopulmonary anastomosis; pulmonary arterioplasty; single ventricle.