New approach in partial cavopulmonary connection

Abstract

The development of pulmonary arteriovenous fistulas after bidirectional cavopulmonary operations, such as the bidirectional Glenn shunt and Kawashima's procedure, has raised concern. Development of these fistulas, which are more frequent than initially thought, can represent a limiting factor in the late outcome of these patients and may even limit the indication for these types of surgery. Whether the fistulas can be reversed by transforming the surgical procedures has yet to be established. In the hope of avoiding this kind of complication, thought to be caused by the lack of passage of a hypothetical hepatic factor through the pulmonary circulation, we have developed an inverted type of bidirectional cavopulmonary connection in which the blood coming from the liver perfuses immediately both lungs. This is made possible by shunting via an intra-atrial tunnel the blood from the superior caval vein directly to the left atrium, and the blood from the inferior caval vein to the right branch of the pulmonary trunk (keeping its bifurcation intact). We describe findings in two patients undergoing successful surgery with this technique. Serial follow-up with contrast echocardiography did not show evidence of arteriovenous pulmonary fistulas. Despite our numbers being small, and the time of follow-up being limited, we believe that it is important to document these and similar cases.

The Fontan procedure: analysis of cohorts and late complications

“…156 ' 157 Others have modified the cavopulmonary connection so as to include hepatic venous blood in the pulmonary circulation. 158 Because pulmonary arteriovenous malformations have been seen in the patient with Weber-Osler-Rendu syndrome, and can be seen in other cardiac malformations where hepatic venous blood is conveyed to the lungs, the role of hepatic venous effluent has yet to be fully defined. 159 ' 160 In some patients with left isomerism, both systemic and pulmonary arteriovenous malformations have been seen, 161 ' 162 although we did not identify any systemic malformations in the large cohort of patients with left isomerism seen in Toronto.…”

Contribuição para o diagnóstico e o tratamento das fístulas arteriovenosas pulmonares após a operação de Glenn bidirecional

“…The inverted Glenn operation, which consisted of the construction of a tunnel inside the right atrium, allowing continuity of the inferior vena cava with the right pulmonary artery, was performed according to a previously published technique 13 . For confirming that the microbubbles do not cross the capillary barrier in the absence of pulmonary arteriovenous fistulae, a control group of 27 healthy children was used.…”

“…Recognizing the importance of the hepatic venous blood return to the lungs for preventing fistulae, Macé et al 37 and the group of this study 13 modified the procedure of the bidirectional Glenn operation to allow a first mandatory passage of hepatic blood through the lungs. Aiming at this, the right pulmonary artery was connected to the inferior vena cava, a procedure called the inverted bidirectional Glenn operation, whose technical details have already been described in a previous publication 13 .…”

“…Aiming at this, the right pulmonary artery was connected to the inferior vena cava, a procedure called the inverted bidirectional Glenn operation, whose technical details have already been described in a previous publication 13 . After surgery, blood of the inferior vena cava has to pass through the lungs, supplying them with the hypothetical hepatic factor.…”