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Eur J Cardiothorac Surg 2006;29:864
© 2006 Elsevier Science NL

Letter to the Editor

Systemic to pulmonary artery shunt in single ventricle

Istanbul University Istanbul Medical Faculty, Department of Cardiovascular Surgery, Millet Caddesi, Capa, 34390 Fatih, Istanbul, Turkey

Received 17 January 2006; accepted 13 February 2006.

^_* Corresponding author. Tel.: +90 212 414 20 00x326 60; fax: +90 212 534 22 32. (Email: emintireli{at}yahoo.com).

Key Words: Single ventricle • Modified BT shunt • Bidirectional Glenn shunt • Fontan procedure

We read with interest the article entitled ‘Surgical Strategy for Pulmonary Coarctation in the Univentricular Heart’ by Kim et al. [1]. There are certain points in the manuscript which should be discussed in more details.

Authors advocate bilateral balanced growth of the pulmonary arteries after performing a modified BT shunt to one of the pulmonary artery branches and patchplasty to the stenotic region of the pulmonary artery. Also, they indicate the procedure is a valid initial surgical strategy in single ventricle patients who are candidates for bidirectional Glenn shunt or Fontan procedure [1].

In the manuscript, the pulmonary coarctation was defined and authors used either echocardiography or chest CT scans for the diagnosis of this pathology. However, the degree of the pulmonary coarctation and whether it created significant hemodynamic changes have not been explained in details.

It is well known that growth of the pulmonary artery branch ipsilateral to the modified BT shunt is more enhanced when compared with the contralateral side [2]. Also, for the patients who are considered for further bidirectional Glenn or Fontan operations, modified BT shunts between the brachiocephalic trunc and the right pulmonary artery (nine patients in the author's series) may lead to distortion of the right pulmonary artery and technically complicate the subsequent Glenn shunt anastomosis. Especially, it is even more important for the off pump Glenn shunt and Fontan operations [3]. Thus, in the view of these points, in patients who will receive single ventricle repair but require a prior systemic to pulmonary artery shunt, in order to mediate homogenous growth of both of the pulmonary arteries and facilitate subsequent bidirectional Glenn or Fontan operations, a shunt to the main pulmonary artery is recommended [2]. At our institution we perform the Glenn shunt and Fontan procedures with the off pump technique. In order to keep right and left pulmonary artery branches untouched and permit homogenous growth of the right and left pulmonary arteries, we perform an ante-aortic shunt between the brachiocephalic trunc and the main pulmonary artery [4]. We believe our technique provides equal enlargement of both of the pulmonary arteries and facilitates subsequent bidirectional Glenn and Fontan operations. Additionally, we do not agree with authors in the idea of patchplasty technique to nonsignificant pulmonary artery stenosis during primary shunt operations being an advantage for subsequent bidirectional Glenn or Fontan operations.

As a conclusion, we do not think that a modified BT shunt between the brachiocephalic trunc and the right pulmonary artery (nine patients in the author's series), and patchplasty to the pulmonary coarctation is an advantage for bilateral pulmonary vasculature and subsequent Glenn or Fontan procedures. We believe in these patients ante-aortic placement of a 4-mm PTFE graft between the brachiocephalic trunc and the main pulmonary artery is a practical technique and advantageous for the pulmonary vasculature and enhances subsequent Glenn shunt or Fontan operations.

References

1. Kim HK, Kim WH, Kim SC, Lim C, Lee CH, Kim SJ. Surgical strategy for pulmonary coarctation in the univentricular heart. Eur J Cardiothorac Surg 2006;29(1):100-104[Epub 2005 Dec 5].[Abstract/Free Full Text]
2. Batra AS, Starnes VA, Wells WJ. Does the site of insertion of a systemic-pulmonary shunt influence growth of the pulmonary arteries?. Ann Thorac Surg 2005;79(2):636-640.[Abstract/Free Full Text]
3. Tireli E, Basaran M, Kafali E, Harmandar B, Camci E, Dayioglu E, Onursal E. Peri-operative comparison of different transient external shunt techniques in bidirectional cavo-pulmonary shunt. Eur J Cardiothorac Surg 2003;23(4):518-524.[Abstract/Free Full Text]
4. Cetin G, Ozkara A, Soyler I, Tireli E. A novel technique for creation of a systemic-to-pulmonary arterial shunt. Cardiol Young 2005;15(1):31-34.[Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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): Emin Tireli Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Ugurlucan, M. Articles by Tireli, E. Search for Related Content PubMed PubMed Citation Articles by Ugurlucan, M. Articles by Tireli, E. Related Collections Congenital - cyanotic