The Off-Pump Fontan Procedure by Simply Cross-Clamping the Inferior Caval Vein Shuichi Shiraishi, MD, Hideki Uemura, MD, Koji Kagisaki, MD, Masahiro Koh,

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The Off-Pump Fontan Procedure by Simply Cross-Clamping the Inferior Caval Vein Shuichi Shiraishi, MD, Hideki Uemura, MD, Koji Kagisaki, MD, Masahiro Koh, MD, Toshikatsu Yagihara, MD, Soichiro Kitamura, MD The Annals of Thoracic Surgery Volume 79, Issue 6, Pages 2083-2088 (June 2005) DOI: 10.1016/j.athoracsur.2004.11.056 Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Diagram of a preparative option at the bidirectional Glenn procedure aiming toward the readily achievable extracardiac Fontan procedure. The central part of the pulmonary artery is augmented, at its inferior aspect, using an autologous pericardial patch (a) or an extended polytetrafluoroethylene tube (b). This is followed by construction of a shunt from the ascending aorta (a) or the brachiocephalic artery, using an extended polytetrafluoroethylene tube (b). The Annals of Thoracic Surgery 2005 79, 2083-2088DOI: (10.1016/j.athoracsur.2004.11.056) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Diagram of the Fontan completion. (a) The systemic-to-pulmonary shunt is divided at first. Then, the artificial pouch, the augmented part of the central pulmonary artery, is clamped and incised open. To that orifice, a new extended polytetrafluoroethylene tube is anastomosed. (b) The inferior vena cava is simply cross-clamped and transected. To obtain an adequate orifice for the anastomosis between the extracardiac conduit and the inferior vena cava, the venoatrial junction is divided obliquely, leaving a small sleeve of the atrial musculature around the inferior vena cava. The inferior vena caval orifice is readily anastomosed to the extracardiac conduit under an excellent vision of the operative field. The Annals of Thoracic Surgery 2005 79, 2083-2088DOI: (10.1016/j.athoracsur.2004.11.056) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Postoperative concentration of enzymes in the serum. These parameters returned to their normal levels within a few days after the operation. Circles = individual values of all patients undergoing the simple clamp technique; bars = mean ± standard error of the mean. (Max ALT = maximum alanine transaminase; Max AST = maximal aspartate transaminase; Max CPK = maximal creatine kinase.) The Annals of Thoracic Surgery 2005 79, 2083-2088DOI: (10.1016/j.athoracsur.2004.11.056) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Developed venovenous communications illustrated by preoperative angiography before the Fontan completion. (a) The azygous vein (arrow) intentionally preserved at the bidirectional Glenn. (b) Other collateral vessels (arrow) developed between the regions of the superior and inferior vena cava in a patient in whom the azygous vein had been divided. The Annals of Thoracic Surgery 2005 79, 2083-2088DOI: (10.1016/j.athoracsur.2004.11.056) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions