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J Thorac Cardiovasc Surg 2009;138:1154-1159
© 2009 The American Association for Thoracic Surgery

Congenital Heart Disease

Improved management of systemic venous anomalies in a single ventricle: New rationale

^a Cardiac Surgery Service of the Medical-Surgical Department of Paediatric Cardiology, Bambino Gesù Paediatric Hospital, Rome, Italy
^b Cardiology Service of the Medical-Surgical Department of Paediatric Cardiology, Bambino Gesù Paediatric Hospital, Rome, Italy
^c Department of Technology and Health of the ISS (Italian National Institute of Health), Rome, Italy
^d Department of Chemical Science and Technology, University of Rome "Tor Vergata," Rome, Italy
^e Department of Mechanics, Politecnico di Torino, Turin, Italy

Received for publication February 17, 2008; revisions received December 11, 2008; accepted for publication April 1, 2009.

^_* Address for reprints: Antonio Amodeo, MD, Dipartimento Medico Chirurgico di Cardiologia Pediatrica, Ospedale Pediatrico Bambino Gesù, Piazza S. Onofrio 4, 00165 Rome, Italy. (Email: antonioamodeo{at}yahoo.it).

Objectives: Two innovative surgical approaches addressing systemic venous anomalies in single-ventricle patients are evaluated.

Methods: Between 2003 and 2007, 7 patients underwent a unifocal bilateral bidirectional cavopulmonary anastomosis, and 5 patients underwent a hepatoazygos venous connection associated with a previous (n = 4) or concomitant (n = 1) Kawashima operation. Computational fluid dynamics simulations allowed investigation of 2 sets of comparative models: (1) bifocal versus unifocal bilateral bidirectional cavopulmonary anastomosis and (2) classic hepatic vein–pulmonary artery channel versus hepatoazygos direct anastomosis for Fontan completion after or combined with the Kawashima operation.

Results: There was 1 hospital death in the unifocal bilateral bidirectional cavopulmonary anastomosis group. At a mean follow-up of 15.6 ± 7.40 months after a unifocal bilateral bidirectional cavopulmonary anastomosis and of 38.7 ± 13.2 months after direct hepatoazygos venous connection, respectively, all 11 survivors are in New York Heart Association class I with functional anastomoses. Computational assessment of bifocal bilateral bidirectional cavopulmonary anastomosis demonstrated weak perfusion between caval veins against symmetric and steady bilateral flow fields in the unifocal arrangement. In the classic post-Kawashima Fontan completion model, the hepatic venous flow to the pulmonary artery was held back by means of preponderant opposite flow, whereas in the direct hepatoazygos venous connection model, the hepatic venous flow merged smoothly into the azygos vein. Power-loss calculation showed no significant difference between bifocal and unifocal bilateral bidirectional cavopulmonary anastomosis topology, whereas the hepatoazygos connection clearly had better energy preservation than the classical connection.

Conclusions: This limited clinical and computational fluid dynamics assessment suggests the efficacy of this new rationale to reduce the additional thrombotic risks produced by systemic venous anomalies in single-ventricle patients.