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Risk factors for morbidity and mortality after a bidirectional Glenn shunt in Northern Thailand

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Owing to the evolution of surgical techniques, the survival rate of patients undergoing a bidirectional Glenn shunt has improved. However, the morbidity and mortality are still high. The aims of this study were to determine the survival rate and risk factors influencing the morbidity and mortality in patients with a functional univentricular heart after a bidirectional Glenn shunt.


One hundred and fifty-one patients who had undergone a bidirectional Glenn operation were enrolled. Early worse outcomes were defined as postoperative death within 30 days and a hospital stay ≥ 30 days.


The median age was 7.1 years (range 0.3–26 years). The median age at the time of the Glenn operation was 2.2 years (range 0.2–15.9 years). The survival rates of patients at 1-, 5-, 10- and 15-year after the Glenn operation were 89%, 79%, 75%, and 72%, respectively. The predictors for the mortality were preoperative mean pulmonary artery pressure ≥ 17 mmHg, preoperative pulmonary vascular resistance index ≥ 3.1 Wood Units·m2 and atrioventricular valve regurgitation. In addition, the independent predictors of an early worse outcome included preoperative mean pulmonary artery pressure ≥ 17 mmHg and diaphragmatic paralysis.


The presence of preoperative atrioventricular valve regurgitation, preoperative mean pulmonary artery pressure ≥ 17 mmHg, preoperative pulmonary vascular resistance index ≥ 3.1 Wood Units·m2, or diaphragmatic paralysis were found to be independent risk factors requiring the good patients’ selection for the Glenn operation and early aggressive management of the diaphragmatic paralysis for reducing morbidity to ensure successful candidature for Fontan completion.

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  1. Alphonso N, Baghai M, Sundar P, Tulloh R, Austin C, Anderson D. Intermediate-term outcome following the fontan operation: a survival, functional and risk-factor analysis. Eur J Cardiothorac Surg. 2005;28:529–35.

    Article  Google Scholar 

  2. Glenn WWL. Circulatory bypass of the right side of the heart. IV. Shunt between superior vena cava and distal right pulmonary artery-report of clinical application. New Engl J Med. 1958;259:117–20.

    Article  CAS  Google Scholar 

  3. Calvaruso DF, Rubino A, Ocello S, Salviato N, Guardi D, Petruccelli DF, et al. Bidirectional Glenn and antegrade pulmonary blood flow: temporary or definitive palliation? Ann Thorac Surg. 2008;85:1389–95.

    Article  Google Scholar 

  4. Gerelli S, Boulitrop C, Van Steenberghe M, Maldonado D, Bojan M, Raisky O, et al. Bidirectional cavopulmonary shunt with additional pulmonary blood flow: a failed or successful strategy? Eur J Cardiothorac Surg. 2012;42:513–9.

    Article  Google Scholar 

  5. Day RW, Etheridge SP, Veasy LG, Jenson CB, Hillman ND, Di Russo GB, et al. Single ventricle palliation: greater risk of complications with the Fontan procedure than with the bidirectional Glenn procedure alone. Int J Cardiol. 2006;106:201–10.

    Article  Google Scholar 

  6. Albanese SB, Carotti A, Di Donato RM, Mazzera E, Troconis CJ, Giannico S, et al. Bidirectional cavopulmonary anastomosis in patients under two years of age. J Thorac Cardiovasc Surg. 1992;104:904–9.

    Article  CAS  Google Scholar 

  7. Lamberti JJ, Mainwaring RD, Spicer RL, Uzark KC, Moore JW. Factors influencing perioperative morbidity during palliation of the univentricular heart. Ann Thorac Surg. 1995;60(6 Suppl):S550–S55353.

    Article  CAS  Google Scholar 

  8. Alejos JC, Williams RG, Jarmakani JM, Galindo AJ, Isabel-Jones JB, Drinkwater D, et al. Factors influencing survival in patients undergoing the bidirectional Glenn anastomosis. Am J Cardiol. 1995;75:1048–50.

    Article  CAS  Google Scholar 

  9. Reddy VM, McElhinney DB, Moore P, Haas GS, Hanley FL. Outcomes after bidirectional cavopulmonary shunt in infants less than 6 months old. J Am Coll Cardiol. 1997;29:1365–70.

    Article  CAS  Google Scholar 

  10. Meza JM, Hickey E, McCrindle B, Blackstone E, Anderson B, Overman D, et al. The optimal timing of stage-2-palliation after the Norwood operation. Ann Thorac Surg. 2018;105:193–9.

    Article  Google Scholar 

  11. Kogon BE, Plattner C, Leong T, Simsic J, Kirshbom PM, Kanter KR. The bidirectional Glenn operation: a risk factor analysis for morbidity and mortality. J Thorac Cardiovasc Surg. 2008;136:1237–42.

    Article  Google Scholar 

  12. Lee TM, Aiyagari R, Hirsch JC, Ohye RG, Bove EL, Devaney EJ. Risk factor analysis for second-stage palliation of single ventricle anatomy. Ann Thorac Surg. 2012;93:614–8.

    Article  Google Scholar 

  13. Baker-Smith CM, Goldberg SW, Rosenthal GL. Predictors of prolonged hospital length of stay following stage II palliation of hypoplastic left heart syndrome (and variants): analysis of the national pediatric cardiology quality improvement collaborative (NPC-QIC) database. Pediatr Cardiol. 2015;36:1630–41.

    Article  Google Scholar 

  14. Cleveland JD, Tran S, Takao C, Wells WJ, Starnes VA, Kumar SR. Need for pulmonary arterioplasty during Glenn independently predicts inferior surgical outcome. Ann Thorac Surg. 2018;106:156–64.

    Article  Google Scholar 

  15. Silvilairat S, Pongprot Y, Sittiwangkul R, Woragidpoonpol S, Chuaratanaphong S, Nawarawong W. Factors influencing survival in patients after bidirectional Glenn shunt. Asian Cardiovasc Thorac Ann. 2008;16:381–6.

    Article  Google Scholar 

  16. Alsoufi B, Manlhiot C, Awan A, Alfadley F, Al-Ahmadi M, Al-Wadei A, et al. Current outcomes of the Glenn bidirectional cavopulmonary connection for single ventricle palliation. Eur J Cardiothorac Surg. 2012;42:42–8.

    Article  Google Scholar 

  17. Scheurer MA, Hill EG, Vasuki N, Maurer S, Graham EM, Bandisode V, et al. Survival after bidirectional cavopulmonary anastomosis: analysis of preoperative risk factors. J Thorac Cardiovasc Surg. 2007;134:82–9.

    Article  Google Scholar 

  18. Francois K, Vandekerckhove K, De Groote K, Panzer J, De Wolf D, De Wilde H, et al. Current outcomes of the bi-directional cavopulmonary anastomosis in single ventricle patients: analysis of risk factors for morbidity and mortality, and suitability for Fontan completion. Cardiol Young. 2016;26:288–97.

    Article  Google Scholar 

  19. Chacon-Portillo MA, Zea-Vera R, Zhu H, Dickerson HA, Adachi I, Heinle JS, et al. Pulsatile Glenn as long-term palliation for single ventricle physiology patients. Congenit Heart Dis. 2018;13:927–34.

    Article  Google Scholar 

  20. Friedman KG, Salvin JW, Wypij D, Gurmu Y, Bacha EA, Brown DW, et al. Risk factors for failed staged palliation after bidirectional Glenn in infants who have undergone stage one palliation. Eur J Cardiothorac Surg. 2011;40:1000–6.

    PubMed  PubMed Central  Google Scholar 

  21. Floh A, Zafurallah I, MacDonald C, Honjo O, Fan C, Laussen P. The advantage of early plication in children diagnosed with diaphragm paresis. J Thorac Cardiovasc Surg. 2017;154:1715–21.

    Article  Google Scholar 

  22. Gruber PJ. Diaphragm plication: when and why to do it. J Thorac Cardiovasc Surg. 2017;154:1712–3.

    Article  Google Scholar 

  23. Joho-Arreola AL, Bauersfeld U, Stauffer UG, Baenziger O, Bernet V. Incidence and treatment of diaphragmatic paralysis after cardiac surgery in children. Eur J Cardiothorac Surg. 2005;27:53–7.

    Article  Google Scholar 

  24. Al-Ebrahim KE, Elassal AA, Eldib OS, Abdalla AHA, Allam ARA, Al-Ebrahim EK, et al. Diaphragmatic palsy after cardiac surgery in adult and pediatric patients. Asian Cardiovasc Thorac Ann. 2019;27(6):481–5.

    Article  Google Scholar 

  25. Keizman E, Tejman-Yarden S, Mishali D, Levine S, Borik S, Pollak U, et al. The bilateral bidirectional Glenn operation as a risk factor prior to Fontan completion in complex congenital heart disease patients. World J Pediatr Congenit Heart Surg. 2019;10:174–81.

    Article  Google Scholar 

  26. Talwar S, Gupta A, Nehra A, Makhija N, Kapoor PM, Sreenivas V, et al. Bidirectional superior cavopulmonary anastomosis with or without cardiopulmonary bypass: a randomized study. J Card Surg. 2017;32:376–81.

    Article  Google Scholar 

  27. Hussain ST, Bhan A, Sapra S, Juneja R, Das S, Sharma S. The bidirectional cavopulmonary (Glenn) shunt without cardiopulmonary bypass: is it a safe option? Interact Cardiovasc Thorac Surg. 2007;6:77–82.

    Article  Google Scholar 

  28. El Midany AAH, Mostafa EA, Mansour SA, Saffan M, Zalat M, El-Sokkary IN, et al. Bilateral bidirectional Glenn: outcome of off-pump technique. Interact Cardiovasc Thorac Surg. 2017;25:745–9.

    Article  Google Scholar 

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Correspondence to Suchaya Silvilairat.

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Sethasathien, S., Silvilairat, S., Lhodamrongrat, C. et al. Risk factors for morbidity and mortality after a bidirectional Glenn shunt in Northern Thailand. Gen Thorac Cardiovasc Surg 69, 451–457 (2021).

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