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J Thorac Cardiovasc Surg 2008;136:1393-1394
© 2008 The American Association for Thoracic Surgery

Letter to the Editor

Reply to the Editor:

Akio Ikai, MD

Iwate Medical University, Department of Cardiovascular Surgery, Morioka, Japan

Kisaburo Sakamoto, MD

Shizuoka Children's Hospital, Department of Cardiovascular Surgery, Shizuoka, Japan

We appreciate Dr Sersar's comments on our recent article, "Feasibility of the Extracardiac Conduit Fontan Procedure in Patients Weighing Less than 10 Kilograms." These comments raise several questions concerning the following: (1) choice of conduit type, (2) anticoagulation therapy after the Fontan procedure, and (3) examination of the pulmonary arteries for evaluating the pulmonary vascular tree.

In our article, we describe our strategy for the extracardiac Fontan operation without fenestration. Our strategy aimed to eliminate cyanosis as soon as possible. Fenestration might reduce the duration of pleural drainage but cannot eliminate cyanosis even after the Fontan procedure. We mentioned in the article that peritoneal drainage might be able to reduce the duration of pleural drainage in small children in particular. In addition to the obvious purpose of the drainage of ascites itself, drainage of ascites also results in the drainage of the inflammatory factors present in the ascites.1Go In our series at least, there were no patients with recurrent ascites after the cessation of the initial peritoneal drainage. We have a chance to use a Contegra conduit2Go if this conduit is an attractive option for reducing ascites and pleural effusion. However, the use of this conduit for the Fontan operation is not permitted in Japan. The fate of the conduit as a xenograft, especially in terms of obstruction of conduit and durability of valve function, over the long term should be investigated.

With regard to anticoagulation agents, we did not previously use warfarin in any small patients because of the complexity of warfarin control. However, we have recently used warfarin in patients with artificial valve replacement or suboptimal conditions after the Fontan operation.

Regardless of the methods used for evaluating Fontan candidates, we believe that the most important evaluation parameters are pulmonary vascular resistance, pulmonary artery pressure, and atrial pressure or ventricular end-diastolic pressure in patients undergoing the bidirectional Glenn procedure. We showed the Nakata index as the reference morphologic index for the pulmonary vascular tree to compare with other study groups, because the body size of our patients was relatively small and there were no alternative conventional indicators of the pulmonary vascular tree.

References

  1. Bokesch PM, Kapural MB, Mossad EB, Cavaglia M, Appachi E, Drummond-Webb JJ, et al. Do peritoneal catheters remove pro-inflammatory cytokines after cardiopulmonary bypass in neonates?. Ann Thorac Surg 2000;70:639-643.[Abstract/Free Full Text]
  2. Baslaim G. Bovine valved xenograft (Contegra) conduit in the extracardiac Fontan procedure: the preliminary experience. J Card Surg 2008;23:146-149.[Medline]




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