BIDIRECTIONAL SUPERIOR CAVOPULMONARY ANASTOMOSIS - HOW YOUNG IS TOO YOUNG

Objective-To define the lowest age at which the bidirectional superior cavopulmonary anastomosis can safely be used in infants with complex congenital heart defects. Design-A retrospective analysis of clinical, echocardiographic, haemodynamic, and angiographic data in four consec utive patients undergoing bidirectional superior cavopulmonary anastom osis below the age of 2 months. Patients-Between November 1990 and Sep tember 1993, four infants less than 8 weeks of age (3, 4, 6, and 7 wee ks) underwent bidirectional superior cavopulmonary anastomosis as a pr imary palliation for complex heart disease. The indication for early s urgical intervention was progression of cyanosis (n = 3) and high pulm onary blood flow causing heart failure (n = 1). In two infants with tr icuspid atresia, surgery was performed through a right thoracotomy wit hout the use of cardiopulmonary bypass. In one infant with double inle t left ventricle and discordant ventriculoarterial connection, cavopul monary anastomosis was combined with an arterial switch procedure. The final infant had double inlet left ventricle with pulmonary atresia; the central pulmonary arteries were virtually discontinuous and each b ranch was supplied by a separate arterial duct. The central pulmonary arteries were reconstructed using the subaortic innominate vein. Tempo rary prostacyclin infusion was used in three patients in the immediate postoperative period. Results-Early postoperative extubation (5, 7, a nd 48 h) was successful in three patients. The youngest child required ligation of the ductus arteriosus four days later because of severe u pper body oedema. The postoperative course was complicated by prolonge d effusions in two patients. All were alive and well 14-48 months post operatively, with satisfactory systemic saturations (80-87%) and haemo dynamic indices. Conclusions-This limited experience challenges the wi dely held belief that the bidirectional superior cavopulmonary anastom osis cannot be used as a primary palliation for complex heart disease in early infancy. A wider experience is required to determine the safe ty and indications for this approach.