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One Step Forward Two Steps Back: Surgical Management Of Failing Glenns
Zachary Spigel, MD MPH, Rachna Prasad, MS, Gavin Cole, Mohan John, MD, Subhadra Shashidharan, MD.
Emory University/Children's Healthcare of Atlanta, Atlanta, GA, USA.
Objectives:Surgical management of failing Glenn physiology includes strategies to augment pulmonary blood flow (addition of a modified Blalock-Taussig-Thomas shunt, creation of an upper body arteriovenous fistula, etc.) or return to stage I physiology, both of which are associated with mortality and pre-Fontan attrition.
Methods:All Glenn operations at our institution from 2007-2025 were reviewed. Patients requiring surgical management of failing Glenn physiology during the index hospitalization were clustered as reoperation to augment pulmonary blood flow (augment) or 2) takedown to stage I physiology (takedown). All statistics are non-parametric.
ResultsA total of 839 patients underwent Glenn during the study period, of which 10 (1.2%) were augmented and 14 (1.7%) takedown. Pre-operative characteristics by cardiac catheterization or echocardiogram were similar (Table). Survival to hospital discharge occurred in 5/10 (50%) augmented, 7/14 (50%) takedown patients. Of patients discharged alive, completion Fontan was achieved in 2/5 (40%) augmented patients and 2/7 (29%) takedown patients. There are three augmented patients who are alive awaiting Fontan. One takedown patient eventually underwent biventricular repair. All other takedown patients (11/14, 79%) have died. At median follow-up among survivors (3.3 years post-Glenn), survival was 50% among augmented patients and 21% among takedown patients.
ConclusionsIn-hospital mortality is high for all patients who fail Glenn physiology during the index hospitalization. Augmented patients who survived the index hospitalization experienced no additional attrition, whereas attrition remained high among the takedown patients.
LPA = Left Pulmonary Artery, RPA = Right pulmonary Artery, SAVV = Systemic Atrioventricular Valve| Variable | Augment | Takedown | p |
| Systemic Left Ventricle | 3 (30%) | 7 (50%) | 0.42 |
| Prior Norwood | 5 (50%) | 4 (29%) | 0.40 |
| Age at Glenn (days) | 132 (113-171) | 144 (114-157) | 0.86 |
| Year of Glenn | 2022 (2013-2024) | 2016 (2014-2022) | 0.43 |
| Mean LPA Pressure | 15 (12-18) | 16 (15-20) | 0.43 |
| Mean RPA Pressure | 15 (12-18) | 17 (15-20) | 0.27 |
| Pulmonary Vascular Resistance | 1.8 (1.2-2.0) | 1.4 (1.1-2.2) | 0.79 |
| SAVV Regurgitation >= Moderate | 1 (10%) | 4 (29%) | 0.36 |
| Systemic Ventricle Function >= Mildly Depressed | 0 (0%) | 1 (7%) | 1.0 |
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