BD Glenn — Cost, Top Hospitals & Success Rates | MyMedicPlus

The Bidirectional Glenn (BD Glenn) procedure, also known as the superior cavopulmonary anastomosis, is a palliative open-heart operation for infants born with complex congenital heart defects resulting in single-ventricle physiology — conditions in which only one of the heart's two pumping chambers is fully functional. Performed at specialised paediatric cardiac surgery centres, it is the second stage in the staged Fontan palliation pathway and typically occurs when the infant is 4–6 months of age.

In normal cardiac anatomy, the right ventricle pumps deoxygenated blood to the lungs while the left ventricle pumps oxygenated blood to the body. In single-ventricle defects, the sole functional ventricle must power both circulations simultaneously, causing severe volume overload, progressive ventricular dilation, and ultimately heart failure if uncorrected. The BD Glenn addresses this by surgically dividing the superior vena cava (SVC) from the right atrium and anastomosing it to the right and left pulmonary arteries bilaterally, allowing the upper body's venous return — approximately 40–50% of total venous return — to flow passively into the lungs without passing through the heart. This dramatically reduces the volume load on the single ventricle.

The 'bidirectional' designation distinguishes this procedure from Glenn's original 1958 unidirectional shunt by routing SVC blood to both pulmonary arteries simultaneously, providing more balanced pulmonary blood flow and better oxygenation. The BD Glenn bridges the patient towards the Fontan completion operation, performed at age 2–4 years, which routes inferior vena caval blood to the pulmonary arteries as well, achieving a complete cavopulmonary circulation.

The BD Glenn is indicated for any congenital heart defect with single-ventricle physiology in which a biventricular repair is anatomically or haemodynamically not feasible. The most prevalent underlying diagnosis is hypoplastic left heart syndrome (HLHS), in which the left ventricle, mitral valve, aortic valve, and ascending aorta are severely underdeveloped, affecting approximately 1 in 4,000 live births. Tricuspid atresia, where absence of the tricuspid valve prevents right ventricular development, is the second most common indication. Other diagnoses include double inlet left ventricle (DILV), pulmonary atresia with intact ventricular septum where the right ventricle is too small to support the pulmonary circulation, unbalanced atrioventricular septal defect, and complex heterotaxy syndromes with malpositioned cardiac structures.

All of these conditions share the haemodynamic consequence of forcing a single ventricle to sustain both pulmonary and systemic perfusion. Without staged palliation, infants with HLHS would not survive beyond the first weeks of life once the ductus arteriosus closes. The neonatal Norwood procedure or hybrid procedure stabilises the infant at birth; the BD Glenn then provides the next haemodynamic optimisation, reducing volume overload and improving the prospects for Fontan completion and long-term ventricular preservation.

Candidates for BD Glenn are infants aged 3–6 months who have successfully undergone first-stage palliation and demonstrate adequate growth, reasonable ventricular function, and pulmonary vascular resistance sufficiently low (ideally below 3 Wood units per square metre) to allow passive pulmonary blood flow after SVC rerouting. Pre-operative cardiac catheterisation is essential to measure pulmonary artery pressures and resistance, characterise pulmonary artery anatomy, and evaluate ventricular function and atrioventricular valve competence. Cardiac MRI or CT angiography supplements echocardiography for detailed anatomical assessment. All candidates are reviewed at a multidisciplinary congenital heart team meeting before surgery.

Contraindications to BD Glenn include elevated pulmonary vascular resistance — if resistance is too high, passive SVC flow cannot enter the pulmonary circulation and the infant would develop severe systemic venous hypertension and low cardiac output post-operatively. Severe pulmonary artery distortion requiring reconstruction, significant atrioventricular valve regurgitation reducing ventricular function, and evidence of pulmonary arteriovenous malformations are important considerations. Infants with airway anomalies, chromosomal syndromes affecting surgical risk, or intercurrent infection require individual assessment. All BD Glenn operations must be performed at high-volume paediatric cardiac surgery centres with a dedicated PCICU, as volume-outcome relationships are strongly established for this surgery.

The standard BD Glenn is performed via median sternotomy using cardiopulmonary bypass, though some centres perform it off-bypass in selected patients to minimise the inflammatory response. The SVC is transected near the right atrium, the cardiac end is oversewn, and the SVC is anastomosed end-to-side to the right pulmonary artery. The anastomosis is then extended across to the left pulmonary artery to achieve bidirectional flow — ensuring both pulmonary arteries receive upper body venous return. Pre-existing aortopulmonary shunts from the Norwood operation are ligated and divided to avoid competitive pulmonary blood flow.

Concomitant procedures frequently performed at the same time as the BD Glenn include pulmonary arterioplasty (reconstruction of stenotic or distorted pulmonary arteries from previous shunts), atrioventricular valve repair to address significant regurgitation, atrial septectomy to allow unobstructed atrial mixing, and creation of a superior vena caval to pulmonary artery anastomosis incorporating a pericardial patch for augmentation. Hybrid Glenn-Fontan single-stage procedures are offered at a small number of highly specialised centres in selected anatomical subsets. Post-operatively, the PCICU team manages haemodynamics, fluid balance, ventilation weaning, and early extubation protocols.

Selecting the most appropriate BD Glenn approach requires a structured assessment of patient-specific factors. The treating specialist evaluates disease severity, prior treatment history, comorbidities, and patient preferences before recommending a specific protocol. Combination approaches are often more effective than monotherapy — integrating pharmacological, procedural, or rehabilitative elements to address multiple disease mechanisms simultaneously. Dose or intensity is titrated incrementally based on clinical response, tolerability, and objective outcome measures. In patients with refractory disease or inadequate response to first-line protocols, escalation to higher-intensity or specialist-delivered treatment options is indicated. Multidisciplinary team (MDT) review ensures that surgical, medical, and allied health perspectives are integrated into the final management plan, particularly for complex or high-risk cases where multiple treatment pathways are viable and the risk-benefit balance requires careful deliberation.

The BD Glenn provides critical haemodynamic benefits that preserve the single ventricle for the long term. By offloading 40–50% of the venous return from the ventricle, it significantly reduces ventricular volume work, slowing progression of myocardial hypertrophy, dilation, and fibrosis. Oxygen saturations typically improve from pre-operative levels of 72–80% to post-operative levels of 80–88%, improving exercise tolerance and reducing the physiological impact of chronic cyanosis on organ development.

At high-volume congenital cardiac surgery centres, in-hospital mortality for the BD Glenn has fallen to 1–3%. Five-year post-Glenn survival at leading centres exceeds 85–90%. Successful completion of the full three-stage Fontan palliation allows many patients to attend school, participate in moderate physical activity, and achieve acceptable quality of life into adulthood. Advances in perioperative care, improved surgical techniques, and specialised Fontan follow-up clinics continue to improve long-term outcomes for this population.

The BD Glenn is a major operation with important early and late complications. Chylothorax — lymphatic fluid leakage into the pleural space — occurs in approximately 3–12% of cases, attributed to disruption of thoracic lymphatic channels. Management includes low-fat medium-chain triglyceride diet, prolonged pleural drainage, and occasionally octreotide infusion or surgical thoracic duct ligation. Pleural and pericardial effusions are common in the early post-operative period and may require repeated drainage procedures.

Low cardiac output syndrome can occur in the early post-operative period, particularly if pulmonary vascular resistance is higher than anticipated or ventricular dysfunction is present; it is managed with inotropic support, afterload reduction, and occasionally extracorporeal membrane oxygenation (ECMO). Long-term, the most important complication specific to the Glenn circulation is the development of pulmonary arteriovenous malformations (PAVMs) — abnormal arteriovenous connections in the lungs that progressively worsen cyanosis. PAVMs are believed to form in the absence of hepatic venous blood flow through the pulmonary circulation and are one of the principal reasons the Fontan completion, which delivers hepatic venous blood to the lungs, is essential.

Following the BD Glenn, children are cared for in the paediatric cardiac intensive care unit (PCICU) for 3–10 days, with continuous monitoring, mechanical ventilation initially, arterial and central venous pressure monitoring, and echocardiographic surveillance. Chest drains are maintained until drainage is minimal; chylous drainage triggers dietary modification. Most infants are extubated within 24–72 hours. Hospital discharge typically occurs at 7–14 days in uncomplicated cases.

After discharge, close cardiological follow-up is essential: appointments at 2 weeks, 6 weeks, 3 months, and every 3–6 months thereafter. Cardiac catheterisation is performed annually or pre-Fontan to measure pulmonary artery pressures, assess pulmonary artery anatomy, and confirm adequacy of pulmonary blood flow. Parents receive detailed guidance on activity restriction, feeding optimisation (especially if chylothorax occurred), recognition of signs of deterioration (cyanosis, poor feeding, respiratory distress, oedema, excessive fatigue), and medication adherence. The Fontan completion procedure is planned at age 2–4 years, guided by the infant's weight, pulmonary artery development, and ventricular function.

Paediatric open-heart surgery including the BD Glenn is among the most resource-intensive surgical procedures globally, reflecting specialised surgical team requirements, prolonged PCICU care, and advanced monitoring equipment. In the United States, BD Glenn surgery with a typical 10-day PCICU stay costs USD 80,000–200,000 or more, excluding transport, accommodation, and ongoing cardiology follow-up. In the United Kingdom, the procedure is covered by the NHS at designated specialist paediatric cardiac surgery centres.

For international families, India offers world-class paediatric cardiac surgery at a fraction of Western costs. JCI-accredited centres including Narayana Health Bangalore (the world's highest-volume congenital heart surgery centre), Apollo Hospitals, and Amrita Institute of Medical Sciences perform BD Glenn procedures with outcomes comparable to leading Western centres, at total costs of USD 6,000–14,000 including surgery, PCICU, and hospitalisation. Thailand (Bumrungrad International, Samitivej) and Turkey (Medical Park Hospital Group) are further alternatives. Families should plan for 4–6 weeks in the destination country, factoring in accommodation, support caregiver costs, and flights.

For infants with single-ventricle congenital heart disease, the staged Fontan palliation — including the BD Glenn as the second stage — represents the globally accepted standard of care. Cardiac transplantation is an alternative for infants who are not candidates for Fontan palliation, most commonly due to severely elevated pulmonary vascular resistance precluding passive pulmonary flow, or severe ventricular dysfunction. Transplantation carries lifelong immunosuppression, the risk of rejection, and limited donor organ availability — making it a last resort rather than a primary strategy in most centres.

In borderline anatomical situations where borderline biventricular repair might be possible, centres may elect to pursue a two-ventricle repair, which entirely avoids the Fontan pathway and provides a more physiological circulation; however, this decision requires highly individualised assessment by an expert multidisciplinary team. Hybrid Glenn-Fontan single-stage completion has been described at a very small number of expert centres for patients who are older at Glenn presentation, potentially avoiding the third staged operation.