J Thorac Cardiovasc Surg 1998;115:964-965
© 1998 Mosby, Inc.
Right heart bypass with an extracardiac conduit: A cautionary tale!
Christopher Lincoln, FRCS
To the Editor:
In this Journal, we
1 have recently commented on our use of total right heart bypass with an extracardiac conduit.
In performing this procedure, taking a generous cuff of the inferior part of the right atrial wall at its junction with the inferior caval vein, we found it possible to "upsize" the diameter of the conduit over and above the extant diameter of the caval vein at the level of the diaphragm.
A more recent experience with this surgical approach in a 4-year-old child with complex cyanotic congenital heart disease revealed a hidden trap: Rapid accumulation of ascites in the early postoperative period was accompanied by a mean gradient of 10 mm Hg between the inferior caval vein (17 mm Hg) and the conduit (7 mm Hg). The difference in pressures had been noticed at the time of the operation but, because of the external appearance of a wide trumpet-shaped lower anastomosis, the measurements had been discounted as "artifact." Because of the increasing ascites, an exploration became necessary when the gradient across the lower anastomosis was also demonstrated by direct manometry.
On takedown, we observed that a large and prominent eustachian valve had been caught up in the anastomosis, producing a partial curtain across the venous pathway. After excision of the valve and reconstruction of the anastomosis, the gradient was abolished.
When writing on prominence of the eustachian and the thebesian valves, Trento and colleagues 2 commented that the structures might be of "functional significance only if it were necessary to perform a Fontan procedure when they might obstruct flow through an atriopulmonary (or atrioventricular) anastomosis." A cautionary tale!
Consultant Cardiothoracic SurgeonRoyal Brompton Hospital,
London SW3 6NP, United Kingdom
12/8/88049
References
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Roberts CS, Peters P, Lincoln C. Right heart bypass with an extracardiac conduit for functionally single ventricle with anomalous pulmonary venous connection to the right atrium. J Thorac Cardiovasc Surg 1997;114:297-8.[Free Full Text]
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Trento A, Zuberbuhler JR, Anderson RH, Park SC, Siewers RD. Divided right atrium (prominence of the eustachian and thebesian valves). J Thorac Cardiovasc Surg 1988;96:457-63.[Abstract]
