Intrapulmonary arteriovenous shunting may be a universal phenomenon in patients with the superior cavopulmonary anastomosis: a radionuclide study.
OBJECTIVE
To evaluate the extent of intrapulmonary right to left shunting in children after bidirectional cavopulmonary anastomosis (BCPA).


METHODS
Prospective study of patients who underwent BCPA in a single centre.


METHODS
17 patients with complex cyanotic congenital cardiac malformations who underwent BCPA at 1-45 months of age (median 21 months) were evaluated 15-64 months postoperatively (median 32 months). Five children between 1 and 10 years (median 5 years) with normal or surgically corrected intracardiac anatomy and peripheral pulmonary circulation who required V/Q scanning for other reasons were used as controls.


METHODS
All patients underwent cardiac catheterisation to exclude angiographically demonstrable venovenous collaterals followed by pulmonary perfusion scanning using (99m)technetium ((99m)Tc) labelled albumen microspheres to quantify the intrapulmonary right to left shunt.


METHODS
Percentage of intrapulmonary right to left shunt.


RESULTS
The mean (SD) level of physiological right to left shunting found in the control group was 5.4 (2.3)%. All patients with BCPA showed the presence of a significantly higher level of intrapulmonary shunting (26.8 (16.9)%, p < 0.001). The degree of shunting was significantly increased in the subgroup of 11 patients with BCPA as the only source of pulmonary blood flow (34.9 (15.8)%), when compared to the six remaining patients with an additional source of pulmonary blood supply (12.0 (2.6)%, p < 0.001). There was a negative correlation between age at BCPA and the shunt percentage found in the patients with a competitive source of pulmonary blood flow (r = -0.63, p < 0. 01).


CONCLUSIONS
Intrapulmonary right to left shunting develops in all patients following BCPA. This may be caused by a sustained and inappropriate vasodilatation resulting from absence or decreased levels of a substance that inhibits pulmonary vasodilatation. Augmenting BCPA with an additional source of blood flow containing hepatic factor limits the degree of intrapulmonary arteriovenous shunting and may help provide successful longer term palliation.
Vettukattil
J J
JJ
Wessex Cardiothoracic Unit and Department of Nuclear Medicine, Southampton University Hospital NHS Trust, Southampton, UK.
Slavik
Z
Z
Lamb
R K
RK
Monro
J L
JL
Keeton
B R
BR
Tsang
V T
VT
Aldous
A J
AJ
Zivanovic
A
A
Johns
S
S
Lewington
V
V
Salmon
A P
AP
D000367:Age Factors; D001164:Arteriovenous Fistula / Q000000981:diagnostic imaging*; D002675:Child, Preschool; D005500:Follow-Up Studies; D018610:Heart Bypass, Right; D006330:Heart Defects, Congenital / Q000601:surgery*; D006801:Humans; D007223:Infant; D011184:Postoperative Period; D011446:Prospective Studies; D011651:Pulmonary Artery / Q000000981:diagnostic imaging* / Q000503:physiopathology; D011652:Pulmonary Circulation; D011667:Pulmonary Veins / Q000000981:diagnostic imaging* / Q000503:physiopathology; D011877:Radionuclide Imaging; D019275:Radiopharmaceuticals; D013668:Technetium Tc 99m Aggregated Albumin
D019275:Radiopharmaceuticals; D013668:Technetium Tc 99m Aggregated Albumin