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J Thorac Cardiovasc Surg 1994;107:1367
© 1994 Mosby, Inc.

LETTERS TO THE EDITOR

Bidirectional inferior vena cava–pulmonary artery shunt

V. S. Luisi, MD, B. Murzi, MD, M. Bernabei, MD, V. Vanini, MD

Ospedale Pediatrico Apuano
Massa, Italy

A. Biagini, MD

Fisiologia Clinico CNR
Pisa, Italy

To the Editor:

Difficulties in the proper sizing of the fenestration in the partial Fontan repair, plus our admiration for the authors, prompted our surgical group to discuss in detail the article, "Quantification of Flow Through an Interatrial Communication: Application to the Partial Fontan Procedure," by Pearl and associates (J THORAC CARDIOVASC SURG 1992;104:1702-8)

Consistent with the results of this experimental study, we have often been faced with an excessively high right-to-left shunt, with considerable arterial oxygen desaturation. We have no confidence in an adjustable interatrial fenestration, and above all we fear the failure of the enlarging effect when the tourniquets are released.

We performed the first bidirectional cavopulmonary shunt without extracorporeal circulation in 1972, anastomosing the superior vena cava (SVC) side to side to the right pulmonary artery (PA). After more than 20 years, through many technical modifications, we have obtained good results with this procedure.

However, considering the difficulty of predicting the right-to-left shunt at the next step of the partial Fontan procedure, we discussed the feasibility of first performing a bidirectional pulmonary shunt with the inferior vena cava (IVC), leaving the SVC draining into the right atrium.

The IVC carries two thirds of the systemic venous return and would allow better arterial oxygenation than a bidirectional SVC-PA shunt. Furthermore, the orthodromal flow through the azygos vein should act as a regulatory system in case of functional obstacles to IVC flow. We expect that the second step, namely, closure of the azygos vein or SVC-PA anastomosis, with consequent two-thirds or total systemic venous blood flow to the PA, will be less troublesome than the modified Fontan procedure.

Closure of the azygos vein is possible today in the hemodynamic laboratory and should be done as an intermediate step in less-than-ideal candidates for the Fontan procedure. This is currently done with the fenestration in the partial Fontan operation, with the advantage of achieving an obligatory increase of pulmonary flow, not dependent on the size of the communication and the pressure gradient between the right and left atrial chambers. In ideal candidates for the Fontan procedure, the bidirectional SVC-PA anastomosis will increase the pulmonary flow, shunting the systemic venous blood return of the upper part of the body, and, in addition, that amount of venous blood that was drained by the azygos vein from the IVC to the SVC will be redistributed between the two caval compartments, still reaching the PA.

Besides hearing a further discussion of the surgical technique to avoid obstruction of the SVC outlet into the atrium by means of a proper intraatrial or extracardiac conduit connecting the IVC to the PA, we would greatly appreciate knowing your own opinion, and that of the University of California at Los Angeles Medical Center group, regarding the preliminary bidirectional IVC-PA shunt.




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 Ann. Thorac. Surg.Home page
L. Mace, P. Dervanian, J. Losay, T. A. Folliguet, J.-M. Grinda, S. Abdelmoulah, J.-F. Verrier, F. Santoro, and J.-Y. Neveux
Bidirectional Inferior Vena Cava-Pulmonary Artery Shunt
Ann. Thorac. Surg., May 1, 1997; 63(5): 1321 - 1325.
[Abstract] [Full Text]

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