Ann Thorac Surg 2000;69:1228
© 2000 The Society of Thoracic Surgeons
ORIGINAL ARTICLES: CARDIOVASCULAR
Invited commentary
Kirk R. Kanter, MDa
a Department of Cardiothoracic Surgery, Emory University School of Medicine, 1365 Clifton Rd, Atlanta, GA 30322, USA
e-mail: kkanter{at}emory.org
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 Introduction
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The paper by McElhinney and colleagues reviews an experience with 76 children who underwent a bidirectional cavopulmonary anastomosis with follow-up cardiac catheterization. Systemic to pulmonary collateral arteries were found in 45 patients (59%). Interestingly, in children undergoing catheterization in 1994 or after, when particular attention was made to identify these collaterals, the incidence of collaterals rose to 40 of 56 patients (71%). This confirms the results of others who have shown similarly high incidences of systemic to pulmonary collaterals in patients both before and after the Fontan procedure when these collaterals are aggressively investigated.
The question is if these collaterals are of clinical significance? At first glance, McElhinney and associates indicate that these collaterals are not clinically important. Specifically, duration of chest tube drainage after the Fontan procedure was significantly shorter in children with collaterals, as well as likelihood of chest tube drainage persisting for greater than 14 days when compared with patients without collaterals. However, when children who underwent catheterization prior to 1994 were excluded (before a concerted effort was made to aggressively identify these collaterals) these differences disappeared. Thus, perhaps the children with prolonged chest tube drainage after the Fontan indeed had collaterals which were unrecognized because they were not aggressively investigated. Furthermore, of the 43 patients who went on to a Fontan procedure, 22 had collaterals yet only 7 of these underwent coil occlusion. The presumption is that in these 7 patients, there must have been some characteristic of the collaterals (size, number, hemodynamic effect) which prompted coil occlusion. If these patients had not had pre-Fontan coil occlusion of collaterals, would they have had prolonged chest tube drainage, increased pulmonary blood flow, and heart failure, and thus altered the results of this study? Certainly, the authors must subscribe to this view since although they note that collaterals were not associated with a higher incidence of prolonged effusions or correlate with poor outcome, they still recommend occlusion of significant collaterals prior to the Fontan procedure.
In summary, this paper confirms that systemic to pulmonary collaterals after a bidirectional cavopulmonary anastomosis are very common, particularly when aggressively investigated in the catheterization laboratory. The authors recommend routine occlusion of large collaterals, although the clinical advantage of this philosophy is not clearly demonstrated in this paper probably due to sampling errors. Until there is a prospective study investigating children with collaterals before the Fontan procedure randomized to coil vs no coils, we feel it makes clinical sense and there is sufficient other evidence to recommend routine occlusion of all significant systemic to pulmonary collaterals at pre-Fontan catheterization.
Related Article
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Incidence and implications of systemic to pulmonary collaterals after bidirectional cavopulmonary anastomosis
- Doff B. McElhinney, V. Mohan Reddy, Wayne Tworetzky, Edwin Petrossian, Frank L. Hanley, and Phillip Moore
Ann. Thorac. Surg. 2000 69: 1222-1228.
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