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Ann Thorac Surg 2005;80:1597-1603
© 2005 The Society of Thoracic Surgeons

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Original article: Cardiovascular

Incorporation of the Hepatic Veins Into the Cavopulmonary Circulation in Patients With Heterotaxy and Pulmonary Arteriovenous Malformations After a Kawashima Procedure

^a Department of Cardiology, Children's Hospital, Boston, Massachusetts
^b Department of Cardiac Surgery, Children's Hospital, Boston, Massachusetts
^c Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
^d Department of Surgery, Harvard Medical School, Boston, Massachusetts

Accepted for publication May 9, 2005.

^_* Address correspondence to Dr McElhinney, Department of Cardiology, Children's Hospital, 300 Longwood Avenue, Boston, MA 02115 (Email: doff.mcelhinney{at}cardio.chboston.org).

BACKGROUND: In patients with polysplenia syndrome and azygous continuation of an interrupted inferior vena cava (IVC), pulmonary arteriovenous malformations (PAVMs) are relatively common after bidirectional cavopulmonary anastomosis (BCPA, Kawashima procedure). Resolution of PAVMs after hepatic vein (HV) inclusion into the cavopulmonary circulation has been reported, but there has been no systematic investigation of the effects of this therapy in a population of more than 3 patients.

METHODS: We studied 16 patients with heterotaxy, univentricular congenital heart disease, and azygous continuation of the IVC who underwent incorporation of the HV into the cavopulmonary circuit for treatment of significant PAVMs after a Kawashima procedure.

RESULTS: The median preoperative systemic arterial oxygen saturation (S_saO₂) was 76% (65%–85%), compared with 89% (85% to 92%) early after BCPA. Among 15 early survivors, the median early postoperative S_saO₂was 76% (56%–85%). In 11 of the 15 survivors, S_saO₂ rose to 90% or greater within a year and remained at 93% or greater at follow-up of 2.8 to 10 years. Four patients had persistent hypoxemia and residual PAVMs at follow-up catheterization 1.5 to 8 years postoperatively; these patients had the most severe hypoxemia prior to HV inclusion, and in 2 the residual PAVMs were unilateral, with HV flow streaming to the contralateral lung, in which PAVMs had resolved.

CONCLUSIONS: Hypoxemia resolved after cavopulmonary incorporation of the HV in the majority of our patients with PAVMs after the Kawashima operation, presumably due to a combination of PAVM resolution and elimination of hepatic venoatrial right-to-left shunting. These findings support the theory that development of PAVMs is facilitated by exclusion of HV effluent from the pulmonary circulation.

Related Article

Creation of a Brachial Arteriovenous Fistula for Treatment of Pulmonary Arteriovenous Malformations After Cavopulmonary Anastomosis

Doff B. McElhinney, Audrey C. Marshall, Peter Lang, James E. Lock, and John E. Mayer, Jr
Ann. Thorac. Surg. 2005 80: 1604-1609. [Abstract] [Full Text] [PDF]

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				T. P. Graham Jr The Year in Congenital Heart Disease J. Am. Coll. Cardiol., June 20, 2006; 47(12): 2545 - 2553. [Full Text] [PDF]

				D. B. McElhinney, A. C. Marshall, P. Lang, J. E. Lock, and J. E. Mayer Jr Creation of a Brachial Arteriovenous Fistula for Treatment of Pulmonary Arteriovenous Malformations After Cavopulmonary Anastomosis Ann. Thorac. Surg., November 1, 2005; 80(5): 1604 - 1609. [Abstract] [Full Text] [PDF]