Invited commentary

Abstract

The article by Yoshida and colleagues [1Yoshida M. Yamaguchi M. Yoshimura N. et al.Appropriate additional pulmonary blood flow at the bidirectional Glenn procedure is useful for completion of total cavopulmonary connection.Ann Thorac Surg. 2005; 80: 976-981Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar] is useful for completion of the total cavopulmonary connection” reminds us once again of the controversy involving the influence of additional pulsatile pulmonary artery blood flow in conjunction with the construction of the bidirectional cavopulmonary shunt as an intermediate step toward completion of the Fontan procedure (total cavopulmonary connection) in correction of single ventricle physiology. There has been much discussion and disagreement concerning ventricular volume and unloading, pulmonary artery growth or lack of growth, particularly in the contralateral pulmonary artery, central venous pressure, pulmonary artery pressure and resistance, systemic oxygen saturations (both early and late), and post-procedure morbidity and mortality. Yet no clear conclusions can be drawn about the usefulness of additional pulmonary blood flow and what remains at the heart of the issue. Of particular and singular importance is simply this: Does additional pulmonary blood flow influence the final outcome by ensuring that the greatest number of candidates will progress to successful outcome after the final stage of the modified Fontan procedure? Yoshida and colleagues have attempted to convince us that it does. However, I do not believe that the authors have proven their hypothesis. They have eloquently demonstrated a suppression of pulmonary artery growth retardation, particularly for those patients with small pulmonary arteries when additional “regulated” pulmonary blood flow is provided along with the bidirectional cavopulmonary shunt. What they have not demonstrated effectively is that it has made any difference in the clinical outcome leading to and after completion of the Fontan procedure, except that the final stage needed to be carried out sooner when additional pulsatile pulmonary artery blood flow was not provided. As the authors point out so clearly, this study is not randomized, the numbers are small, and the two groups are not totally equal, leaving us with yet another study that can not answer the definitive question definitively.