الفهرس 
Acknowledgement
Historical Background of Bidirectional Glenn ProcedureOnly 14 pages are availabe for public view
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Abstract
In summary, Bi-directional Cavo-pulamonary procedure has gained a wide application and considered the palliation of choice for patients with univentricular heart .In this study, we reviewed the literature and covered the surgical aspect for the application of this venous shunt, including the criteria of patients. Surgical techniques, complications and outcome. We also discussed the optimum timing, the criteria and changes in our techniques encountered during this study with the aim to improve the outcome and reduce the morbid complications namely Neurological complications, pleural effusion and superior vena caval syndrome.
In this study, we have 60 patients with univentricular heart who underwent cavo-pulamonary shunt done in University of Leipzig, Heart Centre, Germany and Assiut University Paediatric Heart Surgery Centre, Egypt. Between January 2004 and July 2010 in Leipzig Heart Centre and between March 2010 and March 2012 in Assiut University Paediatric Heart Surgery Centre, 60 patients (45 in Leipzig and 15 in Assiut) aged 2.5 months to 29 years received a bidirectional Glenn shunt with the use of a temporary shunt (in Assiut=Group B) or cardiopulmonary bypass (in Leipzig=Group A). All patients were subjected to the following:
1. Complete preoperative study; including the age, weight, morphology of the univentricular heart with assessment of pulmonary artery size and pressure as well as ventricular functions using both echo-cardiograph and cardiac catheterization.
2. Complete post-operative evaluation of the results and complications with emphasis on the changes encountered during this study.
The aim of the study was to demonstrate the applicability of Bi-directional cavo-pulmonary shunt to palliate children as young as 3 months of age when the criteria of the patients are suitable for doing the operation (in contrary to the opinion of many authors), the difference in outcome by using cardiopulmonary bypass or using the veno-atrial shunt and abolishing or reducing versus leaving all source of pulmonary artery blood flow. We compared all the results, starting from the preoperative data till the mortalities and their analysis in both groups.
from the data outcome in this study we concluded that Bidirectional cavo-pulmonary shunt is a good palliative procedure for patients with univentricular hearts even in age younger than 3 months and improved oxygen saturation provided that the criteria and choice of patients are fulfilled.
One of the limitations of this study was the number of patients investigated; however this number represented the number of patients who were admitted at that period and fulfill the criteria designed in this study.
Another limitation was the lack of long-term follow up and hence this study could not investigate the late complications developed such as decrease in oxygen saturation, and intrapulmonary arteriovenous fistula. We found that because our patient population was from an extremely wide referral base, with significant reluctance and poor parent compliance we could not achieve a long-term follow up.
Recommendations:
1. Although cavo-pulmonary anastomosis is a simple shunt, the proper choice of the patient as regards age, pulmonary artery size and pressure evaluation, pulmonary vascular resistance, ventricular assessment and other associated anomaly are important factors that determine the outcome.
2. The procedure is basically done with cardiopulmonary bypass, and doing the shunt without the cardiopulmonary bypass (with temporary venoatrial shunt) is only in selected cases which it is not suitable in patients who are too young, have hypoplastic pulmonary arterial branches. Caution is indicated when considering off-pump BDG for patients with a history of arrhythmias or who have severe volume overload beside patients requiring any intracardiac repair, had unacceptable PA pressures (> 20 mm Hg), and have any significant atrio-ventricular (AV) valve regurgitation. Also the concept that clamping the SVC without a temporary shunt can lead to decreased cerebral blood flow and put the brain at risk
3. Early extubation, fluid restriction, diuretics and early anticoagulation are important in the postoperative period.
4. In our early and midterm results, with either abolishing or controlling pulmonary flow has excellent outcome among our patients. Although the advantages of antegrade pulmonary blood flow in better oxygenation, lower ICU stay and lesser needed for inotropes, but with higher central venous pressure and higher risk of pleural effusion and chylothorax. Follow up of our patients is needed to detect the long-term results of both groups.
5. Moreover, the experience gained by the whole team about dealing with patients with univentricular heart who underwent Cavopulmonary connection led to better postoperative results was gained.