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J Thorac Cardiovasc Surg 1997;113:808
© 1997 Mosby, Inc.

LETTERS TO THE EDITOR

Total cavopulmonary direct anastomosis

Dipartimento Medico-Chirurgico di Cardiologia Pediatrica
Ospedale Bambino Gesù
Rome, Italy

To the Editor:

In the June 1996 issue of this Journal, van Son, Reddy, and Hanley ¹ described a technique of total cavopulmonary connection by means of direct anastomosis between the superior vena cava (bilateral, in this case) and the pulmonary artery and between the transected inferior vena cava (IVC) and the transected, mobilized pulmonary trunk (PT). No patches or conduits were used.

We are pleased to see that this technique, described by our group in 1993, ² has been used with success by other groups. We pointed out that this procedure combines the advantage of a tubular connection and of full growth potential. Van Son, Reddy, and Hanley fully agree with this assumption.

These authors rightly remark that this technique is easier to use when the ascending aorta is in the L-malposition spatial arrangement; the PT is then located posteriorly and to the right, at the shortest distance from the IVC–right atrial junction. In the case we described, left atrial appendage juxtaposition facilitated the direct anastomosis even more, by reducing the superoinferior axis of the right atrium (i.e., the intercaval distance).

We wish to comment briefly on the article by van Son and colleagues.

1. In their description, the distal anastomosis (IVC-PT) was performed first. We now believe that this is better than performing the bilateral cavopulmonary anastomosis as the initial step, as we had suggested; the superior vena cava is always long enough to allow for the anastomosis with the right pulmonary artery, even if inferiorly displaced by the IVC-PT anastomosis.
   
2. From their Fig. 2, one would assume that the IVC-PT anastomosis lies anterior to the right atrium. The surgeon should also be aware that a posterior course of this tubular connection is also acceptable, probably with lesser tension. Concern for compression by the atrial mass is unwarranted, because of the mean pressure gradient between these structures.
   
3. We agree that an atrial cuff, perhaps a beveled one, may allow a tension-free IVC-PT anastomosis. Occasionally, we have adopted a lateral atrial cuff to bridge a longer IVC-PT distance and completed the anastomosis medially with autologous pericardium (unpublished data).
   
4. This technique implies extensive dissection of the main pulmonary branches, in a way not dissimilar from the Lecompte maneuver for the arterial switch operation. Accordingly, a prior bilateral cavopulmonary anastomosis may be a complicating factor or even a contraindication. When this kind of repair is being planned, consideration should be given to an early total cavopulmonary connection, rather than to performing intermediate orthoterminal steps. Concern for early development of arrhythmias ³ and pulmonary arteriovenous fistulas ⁴ seem to validate this approach for many patients with single ventricle physiology.
   

We wish to congratulate van Son, Reddy, and Hanley for emphasizing again the advantages of this technique, which may well represent, in selected cases, the best solution for a total cavopulmonary connection.

References

1. Van Son JAM, Reddy MV, Hanley FL. Extracardiac modification of the Fontan operation without use of prosthetic material. 1995;110:1766-8.
   
2. Carotti A, Iorio FS, Amodeo A, et al. Total cavopulmonary direct anastomosis: a logical approach in selected patients. Ann Thorac Surg 1993;56:963-4.[Abstract/Free Full Text]
   
3. Manning PB, Mayer JE Jr, Wernovsky G, Fishberger SB, Walsh EP. Staged operation to Fontan increases the incidence of sinoatrial node dysfunction. 1996;111:833-40.
   
4. Bernstein HS, Brook MM, Silverman NH, Bristow J. Development of pulmonary arteriovenous fistulae in children after cavopulmonary shunt. Circulation 1995;92(Suppl):II309-14.
   

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Adriano Carotti Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Di Carlo, D. C. Articles by Amodeo, A. Search for Related Content PubMed PubMed Citation Articles by Di Carlo, D. C. Articles by Amodeo, A.