Background:Residual right ventricular outflow obstruction during Tetralogy of Fallot repair necessitates peri-operative revision often requiring trans-annular patch with its negative sequels. Bidirectional Glenn shunt in this setting reduces trans-pulmonary gradient to avoid revision.Methods:Bidirectional Glenn shunt was added during Tetralogy repair in patients with significant residual obstruction. A total of 53 patients between January, 2011 and June, 2018 were included. Final follow-up was conducted in July, 2018.Results:Mean age at operation was 5.63±3.1 years. Right to left ventricular pressure ratio reduced significantly (0.91±0.09 versus 0.68±0.05; p<0.001) after bidirectional Glenn, avoiding revision in all cases. Glenn pressures at ICU admission decreased significantly by the time of ICU discharge (16.7±3.02 versus 13.5±2.19; p<0.001). Pleural drainage ≥ 7 days was seen in 14 (26.4%) patients. No side effects related to bidirectional Glenn-like facial swelling or veno-venous collaterals were noted. Mortality was 3.7%. Discharge echocardiography showed a mean trans-pulmonary gradient of 32.11±5.62 mmHg that decreased significantly to 25.64±5 (p<0.001) at the time of follow-up. Pulmonary insufficiency was none to mild in 45 (88.2%) and moderate in 6 (11.8%). Mean follow-up was 36.12±25.15 months (range 0.5–90). There was no interim intervention or death. At follow-up, all the patients were in NYHA functional class 1 with no increase in severity of pulmonary insufficiency.Conclusion:Supplementary bidirectional Glenn shunt significantly reduced residual right ventricular outflow obstruction during Tetralogy of Fallot repair avoiding revision with satisfactory early and mid-term results.

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Double Aortic Arch is a rare congenital cardiovascular anomaly. Its first successful surgery was performed by Robert Gross in 1945 at Children Hospital Boston, USA. It accounts for 0.4 to 1% of all congenital cardiac defects. Patients having a Double Aortic Arch mostly present with symptoms in the 1st week of life but depending upon the severity of symptoms can present at any age in childhood. We present a case report of two month old baby with noisy breathing, intermittent cough, gross jugular notch retraction and sub costal recession. His Cardiac CT was subsequently done which showed a Double Aortic Arch of left dominant variety encircling the trachea. Surgery was done and the encircling artery compressing the trachea was recognized, dissected and interrupted. Marked relief of tracheal and/or esophageal compression was evident from operation day. Post operative recovery was speedy. Patient’s follow up of was done at 1, 4 and 24 weeks. His recovery was unremarkable. Currently he was thriving well.