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(Circulation. 2001;103:2699.)
© 2001 American Heart Association, Inc.

Clinical Investigation and Reports

Unrecognized Pulmonary Venous Desaturation Early After Norwood Palliation Confounds p:s Assessment and Compromises Oxygen Delivery

Roozbeh Taeed, MD; Steven M. Schwartz, MD; Jeffrey M. Pearl, MD; Jenni L. Raake, RRT; Robert H. Beekman, III, MD; Peter B. Manning, MD; David P. Nelson, MD, PhD

From the Divisions of Cardiology and Cardiothoracic Surgery, The Heart Center, Children’s Hospital Medical Center, Cincinnati, Ohio.

Correspondence to David P. Nelson, MD, PhD, Division of Pediatric Cardiology, Children’s Hospital Medical Center, 3333 Burnet Ave, OSB-4, Cincinnati, OH 45229-3039. E-mail davenelson{at}chmcc.org

Background—Hemodynamic stability after Norwood palliation often requires manipulation of pulmonary vascular resistance to alter the pulmonary-to-systemic blood flow ratio (p:s). p:s is often estimated from arterial saturation (SaO₂), a practice based on 2 untested assumptions: constant systemic arteriovenous O₂ difference and normal pulmonary venous saturation.

Methods and Results—In 12 patients early (3 days) after Norwood palliation, simultaneous arterial, superior vena caval (SsvcO₂), and pulmonary venous (SpvO₂) oximetry was used to test whether SaO₂ accurately predicts p:s. Stepwise multiple regression assessed the contributions of SaO₂, SsvcO₂, and SpvO₂ to p:s determination. SaO₂ correlated weakly with p:s (R²=0.08, P<0.05). Inclusion of SsvcO₂ and SpvO₂ improved p:s prediction accuracy. Pulmonary venous desaturation (SpvO₂ <95%) was observed frequently (30%), especially at FiO₂ 0.21, but normalized with higher FiO₂ or PEEP in all patients. In 6 patients, FiO₂ was increased incrementally from 0.17 to 0.50 to determine whether this was an effective means to manipulate p:s. p:s failed to change predictably with increased FiO₂. In 5 of 6 patients, however, higher SpvO₂ and SaO₂ enhanced systemic oxygen delivery, as demonstrated by improvement in oxygen extraction.

Conclusions—SaO₂ correlated poorly with p:s because of variability in SsvcO₂ and SpvO₂. A novel observation was that pulmonary venous desaturation occurred frequently early after Norwood palliation but normalized with higher FiO₂ or PEEP. Because unrecognized pulmonary venous desaturation confounds p:s assessment and compromises SaO₂ and oxygen delivery, judicious use of inspired oxygen and PEEP may be beneficial in selected patients early after Norwood palliation.

Key Words: heart defects, congenital • lung • surgery • hypoplastic left heart syndrome • Norwood operation

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