Reply

Abstract

We are pleased to respond to the letter from Dr Konstantinov and colleagues regarding our recent report [1Lee J.R. Lee C. Chang J.M. Bae E.J. Noh C.I. Modified extracardiac Fontan in a patient with separate hepatic venous drainage.Ann Thorac Surg. 2002; 73: 992-993Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar]. As he pointed out, diversion of the hepatic venous blood flow in some way to the pulmonary circulation is desirable in younger children with anomalous systemic venous connection undergoing Fontan operation to prevent the development of pulmonary arteriovenous fistulae. We agree that using a separate conduit for diversion of the hepatic venous flow to the pulmonary circulation carries a potential risk of conduit obstruction or thromboembolism as shown by the report of Konstantinov and colleagues [2Konstantinov I.E. Puga F.J. Alexi-Meskishvili V.V. Thrombosis of intracardiac or extracardiac conduits after modified Fontan operation in patients with azygous continuation of the inferior vena cava.Ann Thorac Surg. 2001; 72: 1641-1644Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar]. In our patient, the inferior caval hepatic veins drained separately into the common atrium. An alternative surgical approach to avoid the use of an intraatrial conduit may be a construction of an intraatrial tunnel for simultaneous diversion of both inferior caval and hepatic venous blood flow. Unfortunately, this was not straightforward in our patient. The intraatrial orifice of the hepatic vein was too close to the opening of the left lower pulmonary vein. Construction of intraatrial tunnel might avoid the use of a separate conduit, but instead, result in catastrophic pulmonary venous obstruction. Allowing the hepatic venous blood to drain into the common atrium with some arterial desaturation may be another surgical option to prevent the potential complications of a separate conduit. However, in this patient, this option, may not be a good alternative, for it may result in the development of a pulmonary arteriovenous malformation or severe cyanosis. Conduit-related problems or pulmonary arteriovenous fistulae? Which are more harmful in the long-term: This question cannot be answered at the present moment. The size of the intraatrial conduit may be too small for the hepatic venous flow as the child grows, as Konstantinov pointed out, but adequate conduit size for unobstructed hepatic venous flow cannot be provided at the present moment. Long-term follow-up is mandatory. The patient is on oral anticoagulation with aspirin and has been followed up for 3 years after operation with no conduit-related problem. We thank Konstantinov and colleagues for their interest in our work.