Prevalence and risk factors for aortopulmonary collateral vessels after Fontan and bidirectional Glenn procedures

Department of Cardiology, Children's Hospital, Boston, Massachusetts 02115.

OBJECTIVES. The purpose of this study was to evaluate the prevalence of and risk factors for aortopulmonary collateral vessels in patients who have undergone a bidirectional Glenn or Fontan procedure, or both. BACKGROUND. Aortopulmonary collateral vessels are frequently observed angiographically in patients after a bidirectional Glenn or Fontan procedure. These vessels may provide a source of pulmonary blood flow competitive with anterograde cavopulmonary flow. METHODS. We performed a retrospective study of all patients (n = 196) who underwent catheterization between January 1, 1988 and February 29, 1992 (n = 268) after bidirectional Glenn or Fontan procedures and reviewed clinical, hemodynamic and angiographic phone data. RESULTS. Collateral vessels were diagnosed in 36% of patients. Patients who underwent the bidirectional Glenn procedure were more likely to have collateral vessels than patients who underwent the Fontan procedure (65% vs. 30%, respectively; p < 0.0001). Patients with a history of a Blalock-Taussig shunt were more likely to have collateral vessels than those without (50% vs. 24%, respectively; p = 0.0006). Discretely identifiable collateral vessels were measurable in 54 (20%) of 268 catheterizations. The total estimated cross-sectional area of these vessels averaged 10.7 +/- 7.2 mm2. In patients who underwent the bidirectional Glenn procedure, a step-up in oxygen saturation from the superior vena cava to the distal pulmonary arteries or an upper lobe filling defect, or both, on pulmonary angiogram predicted total estimated cross-sectional area of collateral vessels. Most collateral vessels originated from the internal mammary arteries (34%) and the thyrocervical trunks (22%). Only 9% of collateral vessels arising from the brachiocephalic vessels were visualized by aortogram; the remainder required selective angiography in the subclavian or more distal arteries. CONCLUSIONS. Aortopulmonary collateral vessels are common after bidirectional Glenn and Fontan procedures. Aortograms often fail to diagnose their presence. The left to right shunt carried by these vessels is associated with a step-up in oxygen saturation in the distal pulmonary arteries. The clinical significance and indications for closure of these vessels are not known.

This article has been cited by other articles:

				J. A. Feinstein, D. W. Benson, A. M. Dubin, M. S. Cohen, D. M. Maxey, W. T. Mahle, E. Pahl, J. Villafane, A. B. Bhatt, L. F. Peng, et al. Hypoplastic left heart syndrome current considerations and expectations. J. Am. Coll. Cardiol., January 3, 2012; 59(1 Suppl): S1 - S42. [Abstract] [Full Text] [PDF]

				T. F. Feltes, E. Bacha, R. H. Beekman III, J. P. Cheatham, J. A. Feinstein, A. S. Gomes, Z. M. Hijazi, F. F. Ing, M. de Moor, W. R. Morrow, et al. Indications for Cardiac Catheterization and Intervention in Pediatric Cardiac Disease: A Scientific Statement From the American Heart Association Circulation, June 7, 2011; 123(22): 2607 - 2652. [Full Text] [PDF]

				A. J. Chin, K. K. Whitehead, and R. L. Watrous Insights After 40 Years of the Fontan Operation World Journal for Pediatric and Congenital Heart Surgery, October 1, 2010; 1(3): 328 - 343. [Abstract] [Full Text] [PDF]

				A. Prakash, M. A. Khan, R. Hardy, A. J. Torres, J. M. Chen, and W. M. Gersony A new diagnostic algorithm for assessment of patients with single ventricle before a Fontan operation J. Thorac. Cardiovasc. Surg., October 1, 2009; 138(4): 917 - 923. [Abstract] [Full Text] [PDF]

				K. K. Whitehead, M. J. Gillespie, M. A. Harris, M. A. Fogel, and J. J. Rome Noninvasive Quantification of Systemic-to-Pulmonary Collateral Flow: A Major Source of Inefficiency in Patients With Superior Cavopulmonary Connections Circ Cardiovasc Imaging, September 1, 2009; 2(5): 405 - 411. [Abstract] [Full Text] [PDF]

				K. K. Whitehead, K. S. Sundareswaran, W. J. Parks, M. A. Harris, A. P. Yoganathan, and M. A. Fogel Blood flow distribution in a large series of patients having the Fontan operation: A cardiac magnetic resonance velocity mapping study J. Thorac. Cardiovasc. Surg., July 1, 2009; 138(1): 96 - 102. [Abstract] [Full Text] [PDF]

				A. J. Powell Aortopulmonary Collaterals in Single-Ventricle Congenital Heart Disease: How Much Do They Count? Circ Cardiovasc Imaging, May 1, 2009; 2(3): 171 - 173. [Full Text] [PDF]

				L. Grosse-Wortmann, A. Al-Otay, and S.-J. Yoo Aortopulmonary Collaterals After Bidirectional Cavopulmonary Connection or Fontan Completion: Quantification With MRI Circ Cardiovasc Imaging, May 1, 2009; 2(3): 219 - 225. [Abstract] [Full Text] [PDF]

				K. Januszewska, A. Stebel, and E. Malec Consequences of Right Ventricle to Pulmonary Artery Shunt at the First Stage for the Fontan Operation Ann. Thorac. Surg., November 1, 2007; 84(5): 1611 - 1617. [Abstract] [Full Text] [PDF]

				K. A. Jayakumar, L. J. Addonizio, M. R. Kichuk-Chrisant, M. E. Galantowicz, J. M. Lamour, J. M. Quaegebeur, and D. T. Hsu Cardiac transplantation after the Fontan or Glenn procedure J. Am. Coll. Cardiol., November 16, 2004; 44(10): 2065 - 2072. [Abstract] [Full Text] [PDF]

				A. Gupta, C. Daggett, S. Behera, M. Ferraro, W. Wells, and V. Starnes Risk factors for persistent pleural effusions after the extracardiac Fontan procedure J. Thorac. Cardiovasc. Surg., June 1, 2004; 127(6): 1664 - 1669. [Abstract] [Full Text] [PDF]

				D. W. Brown, K. Gauvreau, A. M. Moran, K. J. Jenkins, S. B. Perry, P. J. del Nido, and S. D. Colan Clinical outcomes and utility of cardiac catheterization prior to superior cavopulmonary anastomosis J. Thorac. Cardiovasc. Surg., July 1, 2003; 126(1): 272 - 281. [Abstract] [Full Text] [PDF]

				R. Kaulitz, G. Ziemer, T. Paul, M. Peuster, H. Bertram, and G. Hausdorf Fontan-type procedures: residual lesions and late interventions Ann. Thorac. Surg., September 1, 2002; 74(3): 778 - 785. [Abstract] [Full Text] [PDF]

				S. M. Bradley, M. M. McCall, J. J. Sistino, and W. A.K. Radtke Aortopulmonary collateral flow in the Fontan patient: does it matter? Ann. Thorac. Surg., August 1, 2001; 72(2): 408 - 415. [Abstract] [Full Text] [PDF]

				D. B. McElhinney, V. M. Reddy, W. Tworetzky, E. Petrossian, F. L. Hanley, and P. Moore Incidence and implications of systemic to pulmonary collaterals after bidirectional cavopulmonary anastomosis Ann. Thorac. Surg., April 1, 2000; 69(4): 1222 - 1228. [Abstract] [Full Text] [PDF]

				S. L. Starnes, B. W. Duncan, J. M. Kneebone, G. L. Rosenthal, T. K. Jones, R. G. Grifka, F. Cecchin, D. J. Owens, C. Fearneyhough, and F. M. Lupinetti VASCULAR ENDOTHELIAL GROWTH FACTOR AND BASIC FIBROBLAST GROWTH FACTOR IN CHILDREN WITH CYANOTIC CONGENITAL HEART DISEASE J. Thorac. Cardiovasc. Surg., March 1, 2000; 119(3): 534 - 539. [Abstract] [Full Text] [PDF]

				K. R. Kanter, R. N. Vincent, and A. A. Raviele Importance of acquired systemic-to-pulmonary collaterals in the Fontan operation Ann. Thorac. Surg., September 1, 1999; 68(3): 969 - 974. [Abstract] [Full Text] [PDF]

				H. J. C. M. van de Wal, R. Ouknine, D. Tamisier, M. Levy, P. R. Vouhe, and F. Leca Bi-directional cavopulmonary shunt: is accessory pulsatile flow, good or bad? Eur J Cardiothorac Surg, August 1, 1999; 16(2): 104 - 110. [Abstract] [Full Text] [PDF]

				R. M. Freedom, D. Nykanen, and L. N. Benson The physiology of the bidirectional cavopulmonary connection Ann. Thorac. Surg., August 1, 1998; 66(2): 664 - 667. [Abstract] [Full Text] [PDF]

				D. B. McElhinney, S. M. Marianeschi, and V. M. Reddy Additional pulmonary blood flow with the bidirectional Glenn anastomosis: does it make a difference? Ann. Thorac. Surg., August 1, 1998; 66(2): 668 - 672. [Abstract] [Full Text] [PDF]

				M. A. Fogel, P. M. Weinberg, K. B. Gupta, J. Rychik, A. Hubbard, E. A. Hoffman, and J. Haselgrove Mechanics of the Single Left Ventricle : A Study in Ventricular-Ventricular Interaction II Circulation, July 28, 1998; 98(4): 330 - 338. [Abstract] [Full Text] [PDF]

				V. M. Reddy, D. B. McElhinney, N. H. Silverman, S. M. Marianeschi, and F. L. Hanley Partial biventricular repair for complex congenital heart defects: an intermediate option for complicated anatomy or functionally borderline right complex heart J. Thorac. Cardiovasc. Surg., July 1, 1998; 116(1): 21 - 25. [Abstract] [Full Text]

				H. Uemura, T. Yagihara, Y. Kawashima, K. Okada, T. Kamiya, and R. H. Anderson Use of the Bidirectional Glenn Procedure in the Presence of Forward Flow From the Ventricles to the Pulmonary Arteries Circulation, November 1, 1995; 92(9): 228 - 232. [Abstract] [Full Text]