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Ann Thorac Surg 2002;74:2228
© 2002 The Society of Thoracic Surgeons

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Correspondence

Fontan operation in a patient with separate hepatic venous drainage: is there a problem?

^a Division of Cardiovascular Surgery Hospital for Sick Children,Toronto, ON M5G 1X8, Canada

e-mail: igorkonst{at}hotmail.com

To the Editor:

I read with great interest the recent report of Dr Lee and colleagues [1]. They described a patient in whom the inferior vena cava and the hepatic veins drained separately into the common atrium. They diverted the hepatic venous flow into the extracardiac Fontan conduit by means of an 8-mm intraatrial Gore-Tex (W.L. Gore and Associates, Flagstaff, AZ) tube graft. The operation was performed on a 22-month-old patient. A few questions and comments seem to be appropriate.

Will hepatic veins provide sufficient flow to keep this conduit open? Will this shunt become a source of thromboembolism in future? Will the shunt permit an unobstructed hepatic venous flow as the child grows? Unfortunately, these questions cannot be answered at the present time. The future will show. I hope sincerely that none of these complications will happen to the patient described and look forward to a long-term follow-up.

Separate hepatic venous drainage represents a difficult problem in patients undergoing Fontan or Kawashima operation. It is thought that diversion of the hepatic venous drainage to the pulmonary circulation is necessary to prevent pulmonary arteriovenous malformations, at least, in younger children. Thus, the conversion of the hepatic venous blood into the pulmonary circulation is desirable.

The concern is, however, that because of low blood flow from hepatic veins, the risk of conduit thrombosis may be significantly increased. My colleagues and I observed thrombosis of both intracardiac and extracardiac conduits when used for diversion of the separate hepatic venous drainage into Fontan circuit [2]. In our article, we reviewed a number of alternative techniques that have been proposed to direct the hepatic venous blood flow to the pulmonary circulation without prosthetic conduits. Those included anastomosis of the hepatic veins to the azygous vein in case of azygous continuation of the inferior vena cava and a circumferential atrial tunnel from the origin of the hepatic veins to the superior vena cava by means of a flap of the right atrial wall. The benefits of these techniques remain unproven.

I congratulate Dr Lee and colleagues on describing and successful implementation of yet one more promising technique for the conversion of the separate hepatic venous drainage into pulmonary circulation. As the survival of this challenging group of patients improves with advances of pediatric cardiac surgery, the separate hepatic venous drainage becomes an important issue.

References

1. Lee J.R., Lee C., Chang J.M., Bae E.J., Noh C.I. Modified extracardiac Fontan in a patient with separate hepatic venous drainage. Ann Thorac Surg 2002;73:992-993.[Abstract/Free Full Text]
2. Konstantinov I.E., Puga F.J., Alexi-Meskishvili V.V. Thrombosis of intracardiac or extracardiac conduits after modified Fontan operation in patients with azygous continuation of the inferior vena cava. Ann Thorac Surg 2001;72:1641-1644.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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 Author home page(s): Igor E. Konstantinov Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Konstantinov, I. E. Search for Related Content PubMed PubMed Citation Articles by Konstantinov, I. E. Related Collections Congenital - cyanotic