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The bidirectional Glenn (BD Glenn) shunt is a palliative cardiac surgical procedure that connects the superior vena cava (SVC) directly to the right pulmonary artery (RPA), allowing all superior venous blood to flow directly to the pulmonary circulation without passing through the right ventricle. It is a critical intermediate stage in the surgical pathway toward the Fontan circulation for children with single-ventricle congenital heart defects, where one of the two ventricles is too small or structurally abnormal to sustain its normal pumping function.

The procedure is performed under cardiopulmonary bypass or, increasingly, off-pump with temporary SVC clamping and controlled shunting. Through a median sternotomy or right thoracotomy, the SVC is divided and anastomosed end-to-side to the right pulmonary artery. The previously created BT shunt (if present from Stage I palliation) is taken down, and any existing atrial septostomy is enlarged or maintained as required by the haemodynamics of the specific lesion.

Physiologically, the bidirectional Glenn reduces ventricular volume load by 30-40%, as the upper body venous return (approximately 40-50% of total cardiac output) now flows passively to the lungs driven by a venous pressure of only 10-15 mmHg rather than being pumped by the right ventricle. This unloads the single ventricle, reduces the incidence of ventricular hypertrophy and dysfunction, and prepares the pulmonary vasculature for eventual Fontan completion.

The BD Glenn is typically performed between 3 and 6 months of age when the pulmonary vascular resistance has naturally fallen from its elevated neonatal level to a range that allows passive pulmonary blood flow. Pre-operative cardiac catheterisation confirms that pulmonary vascular resistance is below 3 Wood units/m² and that pulmonary artery anatomy is adequate for anastomosis.

The bidirectional Glenn is performed for a wide spectrum of single-ventricle congenital heart diseases, most commonly: hypoplastic left heart syndrome (HLHS), where the left ventricle, mitral valve, and aorta are severely underdeveloped; tricuspid atresia, where the tricuspid valve is absent and the right ventricle is rudimentary; and double-inlet left ventricle (DILV), where both atrioventricular valves open into a single dominant left ventricle. Additional indications include unbalanced atrioventricular septal defect where one ventricle is too small for biventricular repair, pulmonary atresia with intact ventricular septum and severely hypoplastic right ventricle, and various other complex heterotaxy syndromes with a functionally single ventricle.

In all these conditions, the single-ventricle surgical pathway involves three staged operations: Stage I neonatal palliation (Norwood procedure for HLHS, or BT shunt/pulmonary artery banding for other lesions), Stage II bidirectional Glenn at 3-6 months, and Stage III Fontan completion at 2-4 years. The BD Glenn is the essential intermediate step that reduces ventricular volume overload and establishes stable pulmonary blood flow.

Candidates for BD Glenn are infants with single-ventricle anatomy who have survived Stage I palliation and in whom cardiac catheterisation demonstrates: pulmonary vascular resistance below 3 Wood units/m², mean pulmonary artery pressure below 15-18 mmHg, adequate pulmonary artery branch anatomy (Nakata index above 250 mm²/m²), and satisfactory single-ventricle function without significant AV valve regurgitation. The infant should typically weigh at least 4-5 kg at the time of surgery and be 3-6 months of age when pulmonary vascular resistance has fallen to its nadir.

Contraindications include elevated pulmonary vascular resistance exceeding 3-4 Wood units/m² (which would prevent passive pulmonary blood flow), significant distortion or hypoplasia of the pulmonary arteries that would limit adequate anastomosis, severely depressed single-ventricle function, and significant AV valve regurgitation requiring concurrent repair that increases operative risk substantially. Patients with significant systemic venous anomalies (bilateral SVCs, interrupted inferior vena cava with azygous continuation) require modified surgical planning.

The classic bidirectional Glenn uses cardiopulmonary bypass with the SVC divided at the atriocaval junction and anastomosed end-to-side to the superior aspect of the right pulmonary artery. If bilateral SVCs are present, a bilateral (or hemi-Fontan) Glenn may be performed, connecting both SVCs to the pulmonary arteries simultaneously. Alternatively, if the right SVC is small, the two SVCs may be connected with a bridge graft.

The off-pump technique — temporarily dividing and redirecting flow using shunt tubing while constructing the anastomosis — avoids the inflammatory effects of cardiopulmonary bypass and may be preferred at some centres for straightforward cases. The hemi-Fontan procedure (Norwood 2.5) augments the right pulmonary artery confluence with a patch while constructing the Glenn anastomosis and placing a fenestrated patch across the SVC-atrial junction to prepare for later Fontan completion with a lateral tunnel. The treating surgeon individualises the chosen technique based on patient anatomy, the extent and nature of the underlying condition, available equipment, and the balance of procedural benefit against risk — a decision made in consultation with the patient following a thorough informed consent discussion covering all available options. The treatment team works closely with patients and their families throughout the entire care pathway, from initial diagnosis and pre-operative preparation through to post-operative recovery and long-term follow-up.

The bidirectional Glenn reliably achieves its haemodynamic goals: oxygen saturation rises to 75-85% on room air in most patients, and single-ventricular end-diastolic volume decreases by 30-40%. Hospital mortality at experienced centres is less than 2-5% for uncomplicated cases. Survival to Fontan completion is 85-90% in major series, and 10-year survival after the complete Fontan pathway is 85-90% in contemporary cohorts.

Beyond haemodynamic benefit, the BD Glenn allows discharge from hospital and a period of near-normal development at home between surgical stages. Children can attend childcare, develop motor milestones, and grow appropriately. The reduced ventricular volume load decreases the rate of ventricular dysfunction, which is the primary long-term concern in the Fontan circulation. Patient outcomes are optimised when surgery is performed by experienced specialists at high-volume accredited centres, where procedural volume correlates with reduced complication rates, shorter hospital stays, and superior long-term functional results compared to lower-volume institutions.

Pleural effusions (chylothorax or serous effusions) are the most common post-operative complication, occurring in 10-30% of cases due to elevated SVC pressure transmitting to the lymphatic system. These may require prolonged chest tube drainage, dietary modification (medium-chain triglyceride formula), or, rarely, thoracic duct ligation. Phrenic nerve palsy from surgical dissection causes ipsilateral diaphragmatic paralysis and may require diaphragm plication.

SVC syndrome with facial oedema, conjunctival injection, and headache may occur if the SVC-pulmonary artery anastomosis is too tight. Pulmonary arteriovenous malformations (PAVMs) are a late complication developing over months to years due to absence of hepatic blood (containing a hepatic factor that prevents PAVM development) in the pulmonary circulation; they cause progressive cyanosis and require Fontan completion to restore hepatic flow to the pulmonary bed. Arrhythmias, particularly sinus node dysfunction from SVC division, occur in 5-10%.

Hospital stay after BD Glenn is typically 5-14 days. Pleural effusions are the primary reason for prolonged admission. Oxygen saturations of 75-85% are expected and considered adequate; lower saturations may indicate pulmonary arteriovenous malformation development or pulmonary artery distortion. Echocardiography before discharge and at 1-3 month intervals thereafter monitors ventricular function, AV valve competence, and anastomosis patency.

Cardiac catheterisation is performed at approximately 18-24 months of age (before Fontan completion) to assess pulmonary vascular resistance, pulmonary artery anatomy, ventricular pressures, and identify any correctable issues. Activities are restricted based on oxygen saturation — most children tolerate light activity well. Planning for Stage III Fontan completion at 2-4 years is initiated during this interval.

Bidirectional Glenn surgery in the United States costs $60,000-$150,000 when including cardiopulmonary bypass, paediatric cardiac surgery fees, and hospital stay. UK NHS treats all congenital heart disease cases through specialist centres without direct patient cost. Private costs in the UK range from £25,000-£60,000.

In India, the BD Glenn procedure and perioperative care at top paediatric cardiac centres (Narayana Health, Apollo, Amrita) costs $5,000-$12,000, representing 80-90% savings. Thailand and Turkey offer similar procedures at $8,000-$15,000. Families considering international treatment for single-ventricle staged palliation should evaluate the full three-stage pathway cost and logistics, as children require ongoing access to the same centre for Fontan completion. Telemedicine follow-up and local paediatric cardiology care between stages are critical components of international management plans. International patients should factor in the cost of pre-operative testing, post-operative accommodation during recovery, translation services where required, and travel insurance including medical evacuation cover when planning overseas medical treatment.

There is no true medical alternative to staged surgical palliation for single-ventricle congenital heart disease. BT shunt (modified Blalock-Taussig-Thomas shunt) from Stage I palliation provides pulmonary blood flow until the BD Glenn but places excessive volume load on the single ventricle with significant shunt-related complications. The classic (unidirectional) Glenn — connecting the SVC only to the right pulmonary artery without pulmonary confluence — is no longer performed due to progressive cyanosis from pulmonary arteriovenous malformations.

Heart transplantation is an alternative pathway for single-ventricle anatomy but is limited by organ availability, high perioperative mortality, and lifelong immunosuppression requirements. For some borderline cases with marginal biventricular anatomy, individualised decision-making may favour attempted biventricular repair over the single-ventricle palliation pathway.