J Thorac Cardiovasc Surg 1997;113:808-809
© 1997 Mosby, Inc.
Total cavopulmonary direct anastomosis
Frank L. Hanley, MD,
V. Mohan Reddy, MD,
Jacques A. M. van Son, MD
Division of Cardiothoracic Surgery
University of California-San Francisco
505, Parnassus Ave.
San Francisco, CA 94143-0118
Reply to the Editor:
We have read with interest the letter from Di Carlo, Carotti, and Amodeo, which discusses our case report on the use of total cavopulmonary connection without the use of prosthetic material. At the time of our procedure and the subsequent case report, we were unaware of the contributions in this regard by Dr. Carotti and his colleagues. Our failure to cite their experience in our bibliography is clearly an oversight.
We agree wholeheartedly with most of the comments made by Di Carlo, Carotti, and Amodeo in their letter, with one exception. Point 3 suggests that an atrial cuff can be taken around the inferior vena cava, which may allow a more tension-free anastomosis between the inferior vena cava and the pulmonary trunk. This recommendation is somewhat controversial in that the result would involve atrial incisions and atrial suture lines, which might lead to rhythm disturbances. Avoidance of atrial incisions is one of the major attractions, in our opinion, of the extracardiac total cavopulmonary connection. It is not clear to us that the benefit of complete avoidance of prosthetic material would outweigh the potential risks of the atrial incision necessary in such situations.
Since submitting our report, we have performed this procedure again, this time in a patient with situs solitus hypoplastic left ventricle with straddling mitral valve, D-transposition of the great arteries, pulmonary stenosis, and a well-developed main pulmonary artery. Of interest, the left-sided posterior position of the main pulmonary artery did not preclude direct connection to the right-sided inferior vena cava. This patient also had a previously performed bidirectional superior vena cava–pulmonary artery anastomosis, which did not preclude mobilization of the pulmonary arteries and direct connection. We agree with Di Carlo, Carotti, and Amodeo that extensive mobilization of both branch pulmonary arteries (and the superior vena cava–pulmonary connection, if present) must be performed to facilitate the procedure.
