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Ann Thorac Surg 2003;76:2167
© 2003 The Society of Thoracic Surgeons

Correspondence

Usefulness of pulsatile bidirectional cavopulmonary shunt in high-risk Fontan patients

Richard D. Mainwaring, MD, John J. Lamberti, MD

Division of Cardiac Surgery, University of Tennessee, 956 Court St, Suite G212, Memphis, TN 38163, USA

To the Editor:

We read with interest the update by Chikada and associates [1]. We have had an interest in the influence of accessory pulmonary blood flow (APBF) on clinical outcome after the cavopulmonary shunt. It was our initial observation that patients with APBF had a much higher incidence of pleural effusion compared with patients without this accessory flow [2]. More recently, we [3] published our experience demonstrating that patients undergoing a cavopulmonary shunt with APBF had a lower midterm survival (Fig 1). The failure rate for Fontan completion was three times higher (26% versus 8%) in the patients with APBF. It was our conclusion that the adverse effects of volume loading overwhelmed any of the theoretical benefits of accessory blood flow. These data are consistent with the views expressed by Mayer [4] in his commentary on the original 1996 article when he wrote that chronic volume loading would be detrimental to the function of a single ventricle.



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  		Fig 1. Survival of patients after bidirectional Glenn procedure (BDG) compared with that of patients with BDG plus accessory pulmonary blood flow (APBF).

 
At the 28th Annual Meeting of the Western Thoracic Surgical Association (June 2002), Ashburn and co-authors [unpublished data] presented a multiinstitutional study evaluating early outcomes in neonatal tricuspid atresia. In this prospective study of 71 patients, there were five deaths, all of which occurred in the cohort of patients who initially had restricted pulmonary blood flow and who underwent a shunt while maintaining the native source of pulmonary blood flow. The authors concluded that interruption of APBF at the initial shunt operation should be considered. These results underscore the message that patients with a single ventricle do better when the pulmonary blood flow is carefully restricted.

In summary, Chikada and co-workers [1] provided an update on the usefulness of a pulsatile bidirectional cavopulmonary shunt. Their new conclusion was that this strategy is not very effective in the long term. A steadily increasing number of studies suggest that APBF has adverse effects on long-term outcome. Having said this, we agree with Mayer’s concluding remark that "it is highly unlikely that a single management strategy will be optimal for this heterogeneous group of patients."

References

  1. Chikada M., Sekiguchi A., Takayama H., Tonari K., Saito A., Ishizawa A. Usefulness of pulsatile bidirectional cavopulmonary shunt in high-risk Fontan patients. Ann Thorac Surg 2002;74:971-972.[Free Full Text]
  2. Mainwaring R.D., Lamberti J.J., Uzark K., Spicer R.L. Bidirectional Glenn: is accessory pulmonary blood flow good or bad?. Circulation 1995;92(Suppl 2):294-297.[Abstract/Free Full Text]
  3. Mainwaring R.D., Lamberti J.J., Uzark K., Spicer R.L., Cocalis M.W., Moore J.W. Effect of accessory pulmonary blood flow on survival after the bidirectional Glenn procedure. Circulation 1999;100(Suppl 2):151-156.
  4. Mayer J.L., Jr Usefulness of pulsatile bidirectional cavopulmonary shunt in high-risk Fontan patients. Ann Thorac Surg 1996;61:849-850.[Free Full Text]



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