Ann Thorac Surg 1997;63:1177
© 1997 The Society of Thoracic Surgeons
Invited Commentary
Invited Commentary
James A. Alexander, MD
Division of Thoracic and Cardiovascular Surgery, University of Florida College of Medicine, Box 100286, HSC, Gainesville, FL 32610-0286
See also page 1175.
I enjoyed very much having the opportunity to read this report. It is clear that those patients experiencing the devastating complication of choreoathetosis after cardiac operations constitute a group that pediatric cardiac surgeons would wish not to place back on cardiopulmonary bypass, especially if cooling is necessary. The literature is unclear as to the etiology of postbypass choreoathetosis; however, several theories have been expressed. One theory is that the temperature of a perfusate less than 15°C can create central nervous system damage, especially in the basal ganglion. The second is that cerebral ischemia is due to decreased cerebral perfusion from increased collaterals in cyanotic children. However, only two thirds of the reported patients were cyanotic. The outcome is also not known in patients with choreoathetosis who have a second procedure requiring cardiopulmonary bypass. I am of the opinion that the search for an alternate means of accomplishing the Fontan operation other than cardiopulmonary bypass should be commended.
A number of surgeons perform the bidirectional Glenn operation under heparinization and a shunt from the superior vena cava to the right atrium. On occasion, my colleagues and I have found this to be an excellent technique. Now with the increased interest in the extracardiac conduits for the completion of the Fontan there well may be more use of the nonbypass procedure for the bidirectional Glenn operation in the future. I think Burke and associates' operative plan was an excellent one but is clearly more applicable in the larger children who would require Fontan completion, using the femoral vein/right atrial shunt. It may well be possible to put a small, right-angled cannula in the diaphragmatic portion of the inferior vena cava and still maintain adequate length of the inferior vena cava for the anastomosis to the conduit. The other issue would be those patients without a bilateral caval system who may require some ingenuity in placing the partial occlusion clamp on the pulmonary artery/superior vena cava for nonbypass Fontan completion.
I was extremely impressed with the technique, which is one that should be in the pediatric cardiac surgeon's armamentarium.
Related Article
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Extracardiac Fontan Operation Without Cardiopulmonary Bypass
- Redmond P. Burke, Jeffrey P. Jacobs, M. Hashmat Ashraf, Abdulwahab Aldousany, and Anthony C. Chang
Ann. Thorac. Surg. 1997 63: 1175-1177.
[Abstract]
[Full Text]
