Ann Thorac Surg 2006;82:350-352
© 2006 The Society of Thoracic Surgeons
How to do it
Extracardiac Fontan Procedure Bridging the Vertebra for Apico-Caval Juxtaposition
Yoichi Kawahira, MD
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,
Kyoichi Nishigaki, MD,
Takayoshi Ueno, MD
Department of Pediatric Cardiovascular Surgery, Osaka City General Hospital, Osaka, Japan
Accepted for publication July 18, 2005.
* Address correspondence to Dr Kawahira, Department of Pediatric Cardiovascular Surgery, Osaka City General Hospital, 2-13-22 Miyakojimahondori, Miyakojimaku, Osaka, 534-0021, Japan (Email: ykawahir{at}mac.com).
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Abstract
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For 5 patients with univentricular heart associated with apico-caval juxtaposition, an extracardiac Fontan procedure was carried out using an artifical graft bridging the vertebra to avoid graft compression by the vertebra and the ventricle. For 2 patients representing nonconfluency between the inferior caval vein and the hepatic vein, a hand-made, shoetree graft was used. Postoperatively all patients are doing well without a stenotic venous pathway. This extracardiac operation using an artificial graft bridging the vertebra may be advantageous for univentricular heart associated with apico-caval juxtaposition to prevent a postoperative stenotic venous pathway.
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Introduction
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The modified Fontan operation for a univentricular heart has been carried out worldwide with excellent results [1]. Various complications requesting reoperation are sometimes reported, such as obstructed venous pathway, atrial arrhythmia, and pulmonary vein obstruction [2–4].
Apico-caval juxtaposition is a relatively rare feature of the cardiac apex pointing at the same side as the inferior caval vein; dextrocardia associated with the right-sided inferior caval vein or levocardia with the left-sided inferior caval vein. This feature may be a possible cause of stenotic venous pathway after the extracardiac Fontan procedure, because the vertebra may compress the graft on the way from the inferior caval vein to the contralateral pulmonary artery [5].
We retrospectively reviewed our experiences to clarify this issue.
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Technique
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Sixty patients with a univentricular heart have undergone the extracardiac Fontan procedure in our department since April 1997. Five patients in all (4.1%) represented apico-caval juxtaposition, which was confirmed at the catheterization and during operation.
Diagnoses of these 5 patients were complete atrioventricular septal defect in 3, tricuspid atresia in 1, and pulmonary atresia in 1. Atrial arrangement was right isomerism in 3 and situs solitus in 2. Three patients presented the right-sided inferior caval vein with dextrocardia, and the 2 remaining patients had the left-sided inferior caval vein with levocardia. Nonconfluency between the inferior canal vein and the hepatic vein was present in 2 patients with situs solitus. All patients had already undergone a bidirectional cavopulmonary shunt.
The modified Fontan procedure was carried out at the age of 4.1 years to 14 years with a median age of 6 years. After median sternotomy, dissection around the heart was done. The inferior caval vein and the hepatic vein were dissected carefully and extensively to migrate them to the medial side without excessive tension. After establishing cardiopulmonary bypass, an extracardiac graft was anastomosed with the caudal surface of the pulmonary artery. Ventricular fibrillation was induced to cut the inferior caval vein at the lower part of the atrium and to close the atrial end. The graft bridging the vertebra was anastomosed with the inferior caval vein migrated to the medial side without excessive tension. In 2 patients with nonconfluency between the hepatic vein and the inferior caval vein, handmade shoetree conduit [6] was used to make a large anastomosis according to size of the distal orifice (Fig 1). All patients were weaned from the bypass uneventfully. One patient needed a fenestration of 5-mm GoreTex tube (W. L. Gore & Associates, Flagstaff, AZ), which was coil embolized at the cardiac catheterization 3 months after surgery.
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Fig 1. This operative schema shows the modified Fontan procedure using a handmade shoetree extracardiac graft bridging the vertebra for a patient with apico-caval juxtaposition associated with nonconfluency between the inferior caval vein (ICV) and the hepatic vein.
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All 5 patients had been sent to the intensive care unit in stable condition. All were extubated 5.1 ± 2.4 hours after surgery with uneventful recovery, and were discharged. However 1 late death occurred due to pulmonary venous obstruction 1 year after repair of total anomalous pulmonary venous drainage.
Postoperative cineangiogram performed 1 year after surgery showed unobstructed venous pathway from the inferior caval vein to the contralateral pulmonary artery (Fig 2).
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Fig 2. These cineangiograms show images of the postoperative venous pathway after the extracardiac Fontan procedure for apico-caval juxtaposition. The pathway bridged the vertebra without stenosis.
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Comment
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Apico-caval juxtaposition is a relatively rare morphological feature of the cardiac apex pointing at the same side of the inferior caval vein [7]. At the extracardiac Fontan procedure for this entity, the graft has to bridge the vertebra from the inferior caval vein to the contralateral pulmonary artery. The graft may be compressed by the vertebra, which is a possible cause of stenotic venous pathway after the extracardiac Fontan procedure. As a material of an extracardiac graft, a pedicled pericardial conduit was reported to be safe in the Fontan procedure for a 5-year-old patient with apicocaval juxtaposition [5]. However, a bit harder artificial graft may be more favorable in protection of the venous pathway from compression by the vertebra, especially in small patients.
When the inferior caval vein and the hepatic vein are nonconfluent, we would say that it is better to integrate both veins into one to make a large orifice. Another device is a handmade shoetree conduit [6], which is more effective in anastomosing the integrated orifice with the conduit without an obstructed venous pathway.
Another important concern is extensive dissection around the inferior caval vein at the diaphragmatic level. Getting a high mobility by dissection and migrating the inferior caval vein toward the vertebra could prevent the kinking or stenotic venous pathway on the way from the inferior caval vein to the contralateral pulmonary artery.
In our series, we put an artificial graft bridging the vertebra from the inferior caval vein to the contralateral pulmonary artery to prevent postoperative stenotic pathway, and we used a handmade shoetree conduit for nonconfluency between the inferior caval vein and the hepatic vein with good results.
Another possible pathway from the inferior caval vein to the pulmonary artery is behind the ventricle; the graft could run behind the ventricle from the inferior caval vein to the ipsilateral pulmonary artery. In this situation, not the vertebra, but the heavy ventricle may compress the graft, and contrary to this, the ventricle may be compressed by the graft, which is a possible cause of postoperative low cardiac output. Surgeons should decide which side the extracardiac graft should run according to morphology of each heart, neither to compress nor to be compressed. Direct anastomosis between the pulmonary trunk and the inferior caval vein may be chosen for selected patients with apico-caval juxtaposition. However, we recommend the artificial graft, bridging the vertebra from the inferior caval vein to the contralateral pulmonary artery, as described in our series. Furthermore, when we are potently afraid of compression of the conduit by the vertebra, we can go for the Fontan procedure with intra-atrial artificial grafting from the inferior caval vein to the contralateral pulmonary artery [4, 6]. Although this procedure needs long cardiac arrest time to anastomose intra-atrial graft from the inferior caval vein to the contralateral pulmonary artery and residual right-to-left shunt through the anastomosis is often confirmed postoperatively, this procedure may also be an option.
In summary, the extracardiac Fontan procedure with an artificial graft bridging the vertebra would be feasible for the univentricular heart with apico-caval juxtaposition.
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References
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- Girod DA, Fontan F, Deville C, Ottenkamp J, Choussat A. Long-term results after the Fontan operation for tricuspid atresia Circulation 1987;75:605-610.[Abstract/Free Full Text]
- Kawahira Y, Uemura H, Yagihara T, Yoshikawa Y, Kitamura S. Renewal of the Fontan circulation with concomitant surgical intervention for atrial arrhythmia Ann Thorac Surg 2001;71:919-921.[Abstract/Free Full Text]
- Uchida T, Uemura H, Yagihara T, Tsukano S, Kitamura S. Pulmonary venous obstruction after total cavopulmonary connection in heterotaxy Ann Thorac Surg 2002;73:273-274.[Abstract/Free Full Text]
- Yoshikawa Y, Ishibashi-Ueda H, Uemura H, Kawahira Y, Yagihara T. Pathologic findings in atrial musculature seven years after the intraatrial tunnel Fontan Ann Thorac Surg 2002;73:663-664.[Abstract/Free Full Text]
- Kitayama H, Oku H, Matsumoto T, Onoe M. Total cavopulmonary connection using a pedicled pericardial conduit for a patient with apicocaval juxtaposition Ann Thorac Surg 2001;72:1393-1394.[Abstract/Free Full Text]
- Nishigaki K, Yagihara T, Kishimoto H, et al. The modified Fontan procedure with intra-atrial artificial grafting for 7 patients with complex cardiac anomaly Jpn J Cardiovasc Surg 1990;19:1323-1325.
- Calcaterra G, Anderson RH, Lau KC, Shinebourne EA. Dextrocardia-value of segmental analysis in its categorization Br Heart J 1979;42:497-507.[Abstract/Free Full Text]
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Abstract
Introduction
