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J Thorac Cardiovasc Surg 2009;138:535-537
© 2009 The American Association for Thoracic Surgery

Invited Commentary

Discussion

Dr Shunji Sano (Okayama City, Japan). I congratulate Dr Barron and his group on their excellent results. They presented the results of first-stage palliation of HLHS. Their experience with 153 patients over a 4.5-year period shows a 30-day mortality of 12% on right-sided RV–PA, 25% on the left side, and 30% in the control group. They also demonstrated a significant survival benefit in the RV–PA group. No difference in ventricular function was seen between groups. No regional dyskinesia was associated with the RV–PA shunt. Central PA stenosis has the advantage of an RV–PA shunt, especially on the left side.

Since 1998, 61 consecutive patients underwent RV–PA shunts in our unit, and all patients had a left-sided RV–PA shunt. Our 30-day mortality is 6.6%, and 6-month mortality is 10%. Forty-seven patients underwent the bidirectional Glenn procedure, and PA plasty was required in 17 patients. Fourteen patients underwent Hegar dilation only through a bidirectional Glenn anastomosis site. Only 3 patients required patch angioplasty. Twenty-nine patients have reached Fontan compression, with 8 patients requiring PA plasty. Some of them had Hegar dilation only, and only 1 patient required patch aortoplasty. Therefore of 61 patients, only 4 required patch aortoplasty, and all 4 patients had reconstructed distal PA stumps with autologous pericardium.

Therefore we changed our technique of distal PA anastomosis by using a polytetrafluoroethylene cuff graft, which is already reported. Since then, we have had no patients who required PA patch aortoplasty.

As long as pulmonary blood flow is through an RV–PA shunt, theoretically, there is not much difference if the shunt is right or left sided. The reasons why I do RV–PA shunts to the left side are that a left-sided shunt looks natural, it does not cross the aorta, and the RV–PA shunt could be left open at the time . . . [Full Text of this Article]