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J Thorac Cardiovasc Surg 1999;117:1046-1047
© 1999 Mosby, Inc.

LETTERS TO THE EDITOR

The extracardiac Fontan procedure using a pedicled pericardial roll without cardiopulmonary bypass

Department of Cardiovascular Surgery
National Cardiovascular Center
5-7-1 Fujishirodai, Suita
Osaka 565-8565, Japan

The extracardiac Fontan procedure using a pedicled pericardial roll without cardiopulmonary bypass

To the Editor:

We congratulate Okabe and his colleagues for their successful establishment of total cavopulmonary connection using a pedicled autologous pericardial roll without the aid of cardiopulmonary bypass. ¹ We ² used similar surgical maneuvers in our recent series of patients when we wanted to achieve a Fontan circulation.

We initially introduced total cavopulmonary connection without the use of cardiopulmonary bypass in April 1996. Overall, 47 patients have undergone the Fontan procedure at our institution since then, with no operative deaths. In 30 of these patients (61%), the Fontan circulation was established without the use of cardiopulmonary bypass. A pedicled autologous pericardial roll was used as an extracardiac conduit for draining the inferior caval vein in 9 of the 30 patients (30%), including 2 with isomeric right appendages. Age at operation ranged from 13 months to 4 years with a mean of 22 ± 12 months. Seven patients were younger than 2 years old. Postoperative angiography demonstrated smooth and unobstructed channels, as shown in our previous report. ² No obstruction or dilatation was noted through the constructed extracardiac channel by consecutive postoperative echocardiograms, the longest follow-up being 30 months.

On the basis of our experience, the surgeon should pay particular attention to several points for successful achievement of this particular procedure. The temporary bypass placed between the caval veins and the atrial chamber should be appropriately designed so as to minimize resistance and turbulence through the tube. With an effective temporary bypass, caval venous pressures can be acceptable during crossclamping of the caval veins. ²

The second technical point to be noted is the level of transection of the inferior cavoatrial junction. As described in the report of Okabe and colleagues, ¹ it is crucial to leave a sleeve of the atrial musculature around the orifice of the inferior caval vein. If the inferior caval vein is divided exactly at the venoatrial junction, anastomosis of the extracardiac conduit to the orifice of the inferior caval vein is extremely difficult because of the very short distance between the site of cannulation and transection. In addition, our preference is an oblique division of the venoatrial junction, ² differing from the square one shown in their schema. ¹ The oblique incision can provide a sufficiently large anastomosis.

This surgical procedure can also be used in patients with visceral heterotaxy and abnormal connections of the hepatic and inferior caval veins. ² In our 2 patients with isomeric right appendages undergoing the nonpump Fontan procedure using a pedicled roll, an independent hepatic vein was connected directly to the atrium. We placed dual temporary bypasses, one for the hepatic vein and the other for the inferior caval vein. In the setting of visceral heterotaxy, since pulmonary venous connection is frequently abnormal, construction of an extracardiac channel, particularly made of a flexible autologous tissue, can be advantageous to avoid obstruction of the pulmonary venous drainage. ³

The presence of adhesions within the pericardial cavity may militate against use of a pedicled pericardial roll. In 2 of our 9 patients undergoing this surgical procedure, the pericardial cavity had been previously opened for banding of the pulmonary trunk. Although pericardial adhesions were moderate in these patients, a pedicled pericardial roll could be provided without major problems.

Obviously, potential for growth of the constructed channel remains controversial, and long-term results must be investigated to determine efficacy of this surgical procedure. As far as intermediate results are concerned, the nonpump extracardiac Fontan procedure using a pedicled autologous pericardial roll is an attractive option for establishing the Fontan circulation. In this respect, we agree with Okabe and colleagues.

12/8/97379

References

1. Okabe H, Nagata N, Kaneko Y, Kobayashi J, Kanemoto S, Takaoka T. Extracardiac cavopulmonary connection of Fontan procedure with autologous pedicled pericardium without cardiopulmonary bypass. J Thorac Cardiovasc Surg 1998;116:1073-5. [Free Full Text]
   
2. Uemura H, Yagihara T, Yamashita K, Ishizaka T, Yoshizumi K, Kawahira Y. Establishment of total cavopulmonary connection without use of cardiopulmonary bypass. Eur J Cardiothorac Surg 1998;13:504-8. [Abstract/Free Full Text]
   
3. Uemura H. The Fontan type procedure in patients with visceral heterotaxy. Cardiol Young 1998;8:419-22. [Medline]
   

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This Article Alert me when this article is cited Alert me if a correction is posted Citation Map 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 Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Uemura, H. Articles by Kawahira, Y. Search for Related Content PubMed PubMed Citation Articles by Uemura, H. Articles by Kawahira, Y.