Evaluation of cerebral oxygenation and perfusion with conversion from an arterial-to-systemic shunt circulation to the bidirectional Glenn circulation in patients with univentricular cardiac abnormalities

Abstract

Objective: Superior vena cava pressure after the bidirectional Glenn operation usually is higher than that associated with the preceding shunt-dependent circulation. The aim of the present study was to determine whether the acute elevation in central venous pressure was associated with changes in cerebral oxygenation and perfusion.

Design: Single-center prospective, observational cohort study.

Setting: Academic children's hospital.

Participants: Infants with single-ventricle lesions and surgically placed systemic-to-pulmonary artery shunts undergoing the bidirectional Glenn operation.

Interventions: Near-infrared spectroscopy and transcranial Doppler sonography were used to measure regional cerebral oxygen saturation and cerebral blood flow velocity.

Measurements and main results: Mean differences in regional cerebral oxygen saturation and cerebral blood flow velocity before anesthetic induction and shortly before hospital discharge were compared using the F-test in repeated measures analysis of variance. In the 24 infants studied, mean cerebral oxygen saturation increased from 49%±2% to 57%±2% (p = 0.007), mean cerebral blood flow velocity decreased from 57±4 cm/s to 47±4 cm/s (p = 0.026), and peak systolic cerebral blood flow velocity decreased from 111±6 cm/s to 99±6 cm/s (p = 0.046) after the bidirectional Glenn operation. Mean central venous pressure was 8±2 mmHg postinduction of anesthesia and 14±4 mmHg on the first postoperative day and was not associated with a change in cerebral perfusion pressure (p = 0.35).

Conclusions: The bidirectional Glenn operation in infants with a shunt-dependent circulation is associated with an improvement in cerebral oxygenation, and the lower cerebral blood flow velocity is likely a response of intact cerebral autoregulation.

Keywords: bidirectional Glenn shunt; congenital heart defect; hypoplastic left-heart syndrome; modified Blalock-Taussig shunt; near-infrared spectroscopy; single ventricle; transcranial Doppler sonography.