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Ann Thorac Surg 2001;72:2187-2188
© 2001 The Society of Thoracic Surgeons
a Department of Cardiovascular Surgery, Medical Faculty of Istanbul University, Capa, 34390 Istanbul, Turkey
To the Editor
We read with interest the article by Potapov and associates [1]. With the advances in neonatal cardiopulmonary bypass and surgical techniques over the years, many previously performed palliative operations are obsolete and no longer indicated. However, despite these advances, systemic–pulmonary shunt procedures remain an effective method of palliation in neonates and infants with cyanotic congenital heart disease.
We agree with the authors that median sternotomy should be the routine approach for systemic–pulmonary shunt construction. In their 22 patients, Potapov and colleagues used a standard median sternotomy and made a central shunt between the ascending aorta and the main pulmonary artery or pulmonary bifurcation. With increasing knowledge and experience, we have learned that the major disadvantage of a central shunt is the absolute risk of excessive pulmonary blood flow. The authors, however, do not provide information about the incidence of pulmonary edema. Further, in neonates with severely diminished pulmonary blood flow, hemodynamic deterioration can occur during manipulation of the ascending aorta and main pulmonary artery, and this can necessitate urgent institution of cardiopulmonary bypass which carries additional risk for such critically ill patients.
Alkhulaifi and coauthors [2] reported that 44% of their shunt procedures were performed through a median sternotomy. They preferred to construct the shunt between the truncus brachiocephalic trunk and the proximal aspect of the right pulmonary artery. In 3 (4%) of their 75 patients, the operations were performed using normothermic cardiopulmonary bypass. The authors emphasized that this type of shunt is less likely to cause pulmonary edema. The mortality rate in their series was 4%.
Between 1995 and 2000, we performed 20 neonatal shunt operations through a median sternotomy. A 3.5-mm or 4-mm polytetraflouroethylene tube graft was used. In every operation, the proximal anastomosis was constructed to the brachiocephalic trunk and the distal anastomosis, to either the proximal portion of the right pulmonary artery or the retroaortic main pulmonary artery. Only 1 neonate required cardiopulmonary bypass. Because of excessive pulmonary blood flow in 2 patients, tube grafts were partially clipped to reduce size. The overall mortality rate was 5%.
We agree with Potapov and associates that construction of a shunt to the main pulmonary artery is not associated with an increased incidence of pulmonary artery distortion. However, in most neonates, performance of an anastomosis to the main pulmonary artery is generally quite difficult. Morbidity and mortality associated with central shunts are higher than they are for peripheral shunts performed from the brachiocephalic trunk to the pulmonary bifurcation because of excessive pulmonary blood flow and subsequent pulmonary edema. In conclusion, we consider that a median sternotomy, a small shunt (3.5 or 4 mm), and avoidance of an oversized shunt are useful measures to improve the safety of a shunt operation.
References
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