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Ann Thorac Surg 2005;79:2083-2088
© 2005 The Society of Thoracic Surgeons

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Original article: Cardiovascular

The Off-Pump Fontan Procedure by Simply Cross-Clamping the Inferior Caval Vein

Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan

Accepted for publication November 17, 2004.

^_* Address reprint requests to Dr Yagihara, Dept of Cardiovascular Surgery, National Cardiovascular Center, 5–7-1 Fujishiro-dai, Suita, Osaka, 565–8565, Japan (E-mail: yagihara{at}hsp.ncvc.go.jp).

Presented at the Fortieth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 26–28, 2004.

	Abstract

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BACKGROUND: We previously used the Fontan procedure, when applicable, by placing a temporary bypass from the inferior vena cava to the atrium. Alternatively, we have striven to achieve the procedure even without use of a temporary bypass in patients having collaterals between the inferior vena cava and the superior vena cava, so as to simplify the procedure. The azygous vein was intentionally left patent at the bidirectional Glenn procedure in the most recent 9 patients, expecting reasonable venovenous communication at Fontan completion. Surgical results will be described for the preliminary experience.

METHODS: Since 2001, this alternative technique has been attempted in 34 patients undergoing the staged Fontan procedure, and eventually used in 22. Duration between the staged procedures was 4 to 108 months (median, 10 months). We considered that the technique was feasible unless femoral venous pressure exceeded 20 mm Hg immediately after cross-clamping the inferior vena cava. Although catheterization before the Fontan completion illustrated development of venovenous collaterals in 14 patients, oxygen saturation remained greater than 80% throughout the period of the bidirectional Glenn physiology.

RESULTS: In all 22 patients, the extracardiac channel was readily reconstructed with an excellent surgical field of view, without operative mortality. On cross-clamping the inferior vena cava, the systemic circulation could be well maintained by administration of dopamine. Oxygen saturation immediately became approximately 97% to 100%. Maximal pressure gradient was 11 ± 5 mm Hg between the superior vena cava and the femoral vein. Postoperatively, serum concentration of enzymes did not critically increase (maximal aspartate transaminase, 96 ± 89 U/L; alanine transaminase, 65 ± 59 U/L; total bilirubin, 1.8 ± 1.1 mg/dL; creatine kinase, 437 ± 230 U/L).

CONCLUSIONS: This alternative technique, when feasible under the current criteria, was simple and did not provide any clinically significant impediments.

	Introduction

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As a surgical option among various modifications for establishing the Fontan circulation, we have used total cavopulmonary connection, in an extracardiac fashion, without the aid of cardiopulmonary bypass [1, 2]. For this off-pump Fontan procedure, we initially placed a temporary bypass between the inferior vena cava and the atrial cavity. Alternatively, we have striven to achieve the off-pump procedure without use of such temporary bypass in patients having collaterals between the inferior and the superior venae cavae, so as to simplify the operative maneuver. We herein describe our preliminary experience of this procedural device, particularly in terms of its operative maneuvers and early surgical outcomes.

	Material and Methods

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Between April 2001 and October 2003, 65 patients underwent total cavopulmonary connection at our institute by constructing an extracardiac channel for the inferior vena caval drainage. Of these, 27 patients underwent the procedure on cardiopulmonary bypass because intracardiac maneuvers were needed concomitantly with the Fontan completion (cardiopulmonary bypass group). In contrast, cardiopulmonary bypass was not used at all in 38 patients. In 4 of these, routine placement of a temporary bypass was carried out without attempting simple cross-clamping of the inferior vena cava (conventional off-pump 1 group). This was because no venous collaterals were expected for the inferior vena cava such as seen in patients with the inferior vena cava interrupted in the setting of left isomerism. In 22 of the remaining 34 patients, femoral venous pressure did not exceed 20 mm Hg promptly after a test cross-clamping of the inferior vena cava. Eventually, therefore, simple cross-clamping was carried out when the inferior vena cava was divided from the atrial wall, and an extracardiac conduit was anastomosed to that orifice (simple clamping group). This is the real cohort of materials of this report. In 12 patients in whom femoral venous pressure exceeded 20 mm Hg at the time of a test cross-clamping maneuver, a temporary bypass was placed between the inferior vena cava and the atrial cavity as used in the conventional off-pump maneuver (conventional off-pump 2 group).

This article has been selected for the open discussion forum on the CTSNet Web Site: http://www.ctsnet.org.discuss

 

All 34 patients in whom a test clamping of the inferior vena cava was attempted (simple clamping and conventional off-pump 2 groups) had previously undergone the bidirectional Glenn procedure [3]. As a preparation aiming toward the off-pump Fontan procedure, any intracardiac maneuvers were carried out, if considered to be necessary, at the time of the partial right heart bypass procedure. Furthermore, the central part of the pulmonary artery was augmented at its inferior aspect, using an autologous pericardial patch or an extended polytetrafluoroethylene tube, just like a pouch (Fig 1), so that an extracardiac conduit for draining the inferior vena cava could be readily anastomosed to the pulmonary arteries at the time of the Fontan completion in the future. This was followed by construction of a shunt from the ascending aorta or the brachiocephalic artery, using an extended polytetrafluoroethylene tube (3.5 to 4.0 mm in diameter), to avoid thrombosis within the blind-ended pouch. Thus, additional forward flow from the ventricle to the pulmonary arteries was provided in the setting of the bidirectional Glenn physiology [4–6]. The azygous vein was not occluded in the most recent 9 patients, allowing probable venovenous communication between the superior and inferior venae cavae at the time of the future Fontan completion under simple clamping of the inferior vena cava. Concomitantly with the bidirectional Glenn procedure, the so-called Damus anastomosis was carried out in 8 patients, the atrioventricular valve was repaired in 3 patients, and an interatrial communication was created in 8 patients. Data concerning the bidirectional Glenn procedure are summarized in Table 1.

View larger version (19K): [in this window] [in a new window]   Fig 1. Diagram of a preparative option at the bidirectional Glenn procedure aiming toward the readily achievable extracardiac Fontan procedure. The central part of the pulmonary artery is augmented, at its inferior aspect, using an autologous pericardial patch (a) or an extended polytetrafluoroethylene tube (b). This is followed by construction of a shunt from the ascending aorta (a) or the brachiocephalic artery, using an extended polytetrafluoroethylene tube (b).

At the time of the real Fontan completion, the systemic-to-pulmonary shunt was divided at first. Then, the artificial pouch, the augmented part of the central pulmonary artery, was clamped and incised open. To that orifice, a new extended polytetrafluoroethylene tube (16 to 20 mm in diameter; median, 18 mm) was anastomosed. No extensive dissection of the pulmonary arteries was needed at all, because the augmented portion was very easily accessible. Subsequent to injection of 0.15 mL/kg of heparin, the inferior vena cava was simply cross-clamped. Confirming that femoral venous pressure did not exceed 20 mm Hg immediately after this maneuver, the inferior vena cava was transected. To get an adequate orifice for the anastomosis between the extracardiac conduit and the inferior vena cava, we make it a rule to divide the venoatrial junction obliquely, leaving a small sleeve of the atrial musculature around the inferior vena cava [7]. The proximal stump of the atrial side was oversewn, and the distal stump of the inferior vena caval side was anastomosed to the extracardiac conduit, which had been trimmed and tailored to fit (Fig 2).

View larger version (25K): [in this window] [in a new window]   Fig 2. Diagram of the Fontan completion. (a) The systemic-to-pulmonary shunt is divided at first. Then, the artificial pouch, the augmented part of the central pulmonary artery, is clamped and incised open. To that orifice, a new extended polytetrafluoroethylene tube is anastomosed. (b) The inferior vena cava is simply cross-clamped and transected. To obtain an adequate orifice for the anastomosis between the extracardiac conduit and the inferior vena cava, the venoatrial junction is divided obliquely, leaving a small sleeve of the atrial musculature around the inferior vena cava. The inferior vena caval orifice is readily anastomosed to the extracardiac conduit under an excellent vision of the operative field.

	Results

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All 22 patients undergoing the simple clamping technique survived the alternative surgical procedure and were discharged in good condition. Furthermore, there was no operative mortality present in all other patients either undergoing the Fontan procedure on cardiopulmonary bypass (cardiopulmonary bypass group) or undergoing the off-pump Fontan completion with placement of a temporary bypass (conventional off-pump 1 and 2 groups). In addition, the attempted test clamping of the inferior vena cava in patients of the conventional off-pump 2 group did not produce any obvious clinical impediments such as signs of renal or liver dysfunction.

With simply cross-clamping the inferior vena cava, the operative maneuver for the inferior anastomosis for the extracardiac channel was extremely easy to establish, under an excellent surgical field of view, in all 22 patients.

At the time of cross-clamping of the inferior vena cava, the overall circulation could be well maintained by administering dopamine (approximately 2 to 9 µg·kg^–1·min^–1) and also by rapidly infusing a certain amount of Ringer’s lactate solution (approximately 100 to 250 mL). Systemic oxygen saturation swiftly became approximately 97% to 100%. Maximal pressure gradient was 11 ± 5 mm Hg between the superior vena cava and the femoral vein during cross-clamping of the inferior vena cava. Maximal femoral venous pressure during cross-clamping of the inferior vena cava was 22±4mmHg. Cross-clamping time was 32 ± 6 minutes.

Postoperative serum concentrations of enzymes did not increase drastically, the maximal levels being 65 ± 35 U/L for aspartate transaminase, 41 ± 25 U/L for alanine transaminase, 1.5 ± 1.0 mg/dL for total bilirubin, and 403±192 U/L for creatine kinase. These returned to their standard values promptly in the intensive care unit (Fig 3). Eighteen patients were extubated within 12 hours and another 2 patients between 12 and 24 hours after the surgical procedure. Postoperative echocardiographic examinations routinely and consecutively carried out demonstrated no obstruction through the channel from the inferior vena cava to the pulmonary arteries in any patient. Catheterization 1 year after the Fontan completion has been performed in 15 patients, showing no pressure gradient across the channel reconstruction.

View larger version (14K): [in this window] [in a new window]   Fig 3. Postoperative concentration of enzymes in the serum. These parameters returned to their normal levels within a few days after the operation. Circles = individual values of all patients undergoing the simple clamp technique; bars = mean ± standard error of the mean. (Max ALT = maximum alanine transaminase; Max AST = maximal aspartate transaminase; Max CPK = maximal creatine kinase.)

View larger version (110K): [in this window] [in a new window]   Fig 4. Developed venovenous communications illustrated by preoperative angiography before the Fontan completion. (a) The azygous vein (arrow) intentionally preserved at the bidirectional Glenn. (b) Other collateral vessels (arrow) developed between the regions of the superior and inferior vena cava in a patient in whom the azygous vein had been divided.

	Comment

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To place a temporary bypass efficiently, extensive dissection is carried out around the inferior venoatrial connection. Even with such a well-arranged maneuver, a tube placed for temporary diversion of blood may interfere with making a smooth anastomosis in a limited operative field. When we use the alternative method of simple cross-clamping, in contrast, we could readily achieve the anastomosis with no technical difficulty at all. Its efficacy is more obvious when the Fontan procedure is established in smaller children on the policy of earlier Fontan establishment [11].

To simply cross-clamp the inferior vena cava, some native bypasses are indispensable for diversion of the inferior vena caval drainage. Several venovenous collaterals are known to be present between the regions of the superior and inferior venae cavae, such as those through the veins within the thoracic wall and those through the venous network around the vertebrae [12, 13]. The azygous and hemiazygous venous system is unequivocally one of these collaterals, if these veins are patent at the time of cross-clamping of the inferior vena cava.

In the very first patient in whom we successfully used the simple clamping technique, the bidirectional Glenn procedure had been performed at another hospital, and the azygous vein had been ligated. Even so, the simple cross-clamping maneuver was possible because of developed venovenous collaterals, other than the azygous venous system, subsequent to the previous bidirectional Glenn procedure. After this experience, we made it a rule to leave the azygous vein patent when the Fontan establishment is approached in a staged fashion.

Although we considered potentially complicating aspects of this modification [14–18], we dared to choose it because our strategy was for Fontan completion at 6 months, a relatively short time, after the bidirectional Glenn procedure. In addition, since 1985, our preference has been to maintain adjusted additional flow from the ventricle to the pulmonary arteries at the time of this partial right heart bypass [4]. Owing to this augmented blood flow to the lungs, oxygen saturation after the bidirectional Glenn procedure was usually 80% to 90%, and there was no worry of hypercyanosis even if the azygous vein was left open. In reality and fortunately, as shown in this series of patients, systemic oxygen saturation was maintained greater than 80% throughout the term of bidirectional Glenn physiology. Of course, it remains most likely contentious whether or not the azygous vein can be left patent even for the time being. We would recall, nonetheless, the fact that the azygous vein is not the only channel producing venovenous connections, but miscellaneous veins should contribute to such collateral circulation. No surgeon divides routinely the hemiazygous vein or internal thoracic veins at the time of the bidirectional Glenn procedure. We had no patients in whom coil embolization was needed to occlude such venovenous collaterals for progressive desaturation subsequent to the bidirectional Glenn procedure.

At the time of simple cross-clamping of the inferior vena cava, congestion of the abdominal organs is obviously a matter of concern related to possible inadequate drainage [19]. Our decision-making criterion during the test clamping was based on the fact that a transient systemic venous pressure of 20 mm Hg can be tolerated in the course of postoperative care in the Fontan patients. On the basis of postoperative serum concentrations of hepatic enzymes, congestive failure was not critically significant at all in patients undergoing the simple cross-clamping technique. Although unable to be compared in a statistical fashion, these clinical values were not inferior, at least, to those seen in our patients undergoing the off-pump Fontan procedure using a temporary bypass from the inferior vena cava to the atrium. There was no difference between these groups with the off-pump Fontan procedure in terms of any other clinical courses, including separation from respirator and postoperative accumulation of ascites.

Management by the anesthetist is of practical importance for maintaining a stable overall circulation. It is required that a sudden decrease in cardiac preload when the inferior vena cava is cross-clamped be treated promptly. Recently, we prefer a posture in which a surgical table is tilted to have the patient’s head down. During cross-clamping the inferior vena cava, systemic oxygen saturation immediately increases to more than 95%. This should be key, being beneficial for ventricular function and other bodily organs. In other words, at the time of cross-clamping the inferior vena cava, the circulation becomes almost Fontan-compatible, although moderately in a low cardiac output status. Urine output is maintained throughout the cross-clamping. When the real Fontan circulation is commenced with the inferior vena cava unclamped, overall circulation instantly becomes notably better. Coagulation disorder is minimal, so that blood transfusion is not always necessary even in small children.

On the basis of our preliminary experience, we herein conclude that the alternative method of simple clamping of the inferior vena cava is plain and safe, when it is confirmed intraoperatively that the maneuver is really feasible. A certain preparation may be needed, such as preservation of the azygous venous system at the time of the bidirectional Glenn procedure. A proper hemodynamic management during operation is another factor for promoting this option.

	Discussion

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DR KARLA G. CHRISTIAN (Nashville, TN): Can you comment on the age and weight, ranges and means, for these 25 patients?

DR SHIRAISHI: Weight, there are no available data at present.

DR CHRISTIAN: What age were your patients?

DR SHIRAISHI: Median age was 1 year.

DR CARL BACKER (Chicago, IL): Is anyone else out there in the audience doing the Fontan completion without cardiopulmonary bypass?

DR ED PETROSSIAN (Madera, CA): Yes. Do you have a comment? We do most of our Fontans now off bypass and we’ve had very good results with it. We haven’t had any problems.

DR BACKER: And do you use a technique similar to that discussed in this presentation?

DR PETROSSIAN: We don’t do a graft to the pulmonary artery, we do the pulmonary artery side off-pump and we do the inferior vena caval side off-pump at the same time.

DR VINCENT TAM (Fort Worth, TX): We have been doing the Fontan off bypass since about 1995. And I’d like to congratulate the authors. I think it’s a very nice presentation. I have a couple of questions.

What size Gore-Tex shunt do you put in to make that pouch work to prepare for that?

DR SHIRAISHI: Shunt size is mainly the 3 mm.

DR TAM: And you’ve obviously not done a fenestration for all these Fontans, is that correct?

DR SHIRAISHI: In these patients, in only 3 patients was a fenestration carried out. And the size was about 5 mm in diameter.

DR TAM: How do you do your fenestration with the extracardiac conduit?

DR SHIRAISHI: A very short extended polytetrafluoroethylene tube interposed between the atrial cavity and the new extended polytetrafluoroethylene tube.

DR TAM: Do you think your method without using a bypass shunt, do you think that influences your incidence of postoperative effusions?

DR SHIRAISHI: Pleural effusion was not greater than those in the cardiopulmonary bypass group.

DR EMILE A. BACHA (Chicago, IL): I have a quick question regarding leaving the azygous vein open. I’m very intrigued by it, because typically you would ligate the azygous vein and only the best candidates, ie, low pulmonary artery pressure patients, could tolerate no ligation of the azygous vein. Your preoperative saturation was 86% to 87%, I believe, before the Fontan. Could you comment a little bit on that? And do you always leave the azygous vein open?

DR SHIRAISHI: Providing the Fontan completion is not expected according to the timing after the bidirectional Glenn procedure, we would divide the azygous vein as conditions allow. And a relatively high oxygen saturation level is caused by the central systemic tube providing a shunt.

	References

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This Article Abstract Full Text (PDF) Online Discussion Alert me when this article is cited Alert me if a correction is posted Citation Map 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): Shuichi Shiraishi Hideki Uemura Masahiro Koh Toshikatsu Yagihara Soichiro Kitamura Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Shiraishi, S. Articles by Kitamura, S. Search for Related Content PubMed PubMed Citation Articles by Shiraishi, S. Articles by Kitamura, S. Related Collections Congenital - cyanotic