Pre-Glenn aorto-pulmonary collaterals in single-ventricle patients.
Sharma VJ, Carlson L, Esch J, Gopal M, Gauvreau K, Wamala I, Muter A, Porras D, Nathan M.Cardiol Young. 2023 Dec;33(12):2589-2596. doi: 10.1017/S1047951123000665. Epub 2023 Apr 17.PMID: 37066762
Take Home Points
- Male sex, age at pre-bidirectional Glenn catheterization and increased Qp:Qs are associated with a moderate to severe AP collateral burden.
- AP collateral burden is not associated with death, transplantation, or the incidence of pulmonary artery interventions.
- Of the patients who need an intervention for AP collaterals, more than half need only a single intervention.
Commentary from Dr. Jonathon Hagel (C.S. Mott Children’s Hospital, University of Michigan), section editor of Congenital Heart Disease Interventions Journal Watch:
Aorto-pulmonary (AP) collaterals are commonly found in single ventricle patients due to presumed hypoxia-induced vascular endothelial growth factor activity. The authors sought to describe the risk factors for developing AP collaterals following the Norwood procedure. They secondarily sought to determine in AP collateral burden has an impact on death, transplantation, or pulmonary artery interventions.
From January 2011 until March 2016, 104 patients underwent the Norwood procedure for various forms of single ventricle heart disease, the most common of which was hypoplastic left heart syndrome (77.9%) with Sano shunt modifications in most cases (78.8%). 84 patients underwent both a pre-bidirectional Glenn catheterization and subsequent bidirectional Glenn procedure and thus were included in the analysis. AP collateral interventions were performed during the pre-bidirectional Glenn catheterization in 54.8% of cases. AP collateral interventions were performed after the bidirectional Glenn procedure in 82% of cases and of the cases that underwent intervention for AP collaterals, 45.2% underwent a single procedure to target the collaterals.
On multivariable analysis, male sex (OR 3.36; 95% CI 1.17-11.4), age at pre-bidirectional Glenn assessment (OR 2.12; 95% CI 1.33-3.39 per month increase) and Qp:Qs ratio (OR 1.23; 95% CI 1.08-1.41 per 0.1 unit increase) were significantly associated with moderate to severe AP collateral burden. AP collateral burden diagnosed at the time of pre-bidirectional Glenn catheterization was not associated with death or transplantation (HR 1.19; 95% CI 0.37-2.61). The incidence of pulmonary artery intervention did not vary significantly based on severity of AP collateral burden.
The authors conclude that AP collateral burden after the Norwood procedure is common and that Qp:Qs, male sex, and age of the pre-bidirectional Glenn catheterization are strong markers of AP collateral burden but the presence of AP collaterals does not confer an increased risk of death, transplantation, or pulmonary artery intervention. Due to the lack of well-established guidelines for the diagnosis or management of AP collaterals, the frequency and timing of intervention more represent an institutional approach rather than a clinical indication for intervention which makes inference on association with long term outcomes difficult though at least in this single center study, severity of AP collateral burden was not associated with adverse long-term outcomes.
