1. Extracardiac Fontan With Direct Cavopulmonary Connections
Roxane McKay, MD, Joseph A. Dearani, MD 
The Annals of Thoracic Surgery 
Volume 85, Issue 2, Pages (February 2008)
DOI: /j.athoracsur
Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

2. Fig 1
(A) The arterial duct was divided and the left pulmonary artery was mobilized into lobar branches. In the beating, nonejecting heart, the pulmonary trunk (MPA) was divided exactly at the sinutubular junction and its cardiac end was closed. The superior caval vein (SVC) was divided above the sinus node and the cardiac end was closed, taking care to exclude air. Upward SVC retraction facilitated complete dissection of the right pulmonary artery and also into its lobar branches. (B) Downward diaphragm displacement allowed careful incision of pericardial attachments to the inferior caval vein (IVC) and hepatic veins, increasing their intrapericardial length by several centimeters. Continuing this dissection along the right pericardial reflection allowed the pulmonary veins (PV) to fall away from the atrium and increased space for the pathway. The mobilized MPA would be then brought to the side of the inferior caval vein, confirming that direct connection was possible. (C) After cross clamping the aorta, the inferior caval vein detachment started anteriorly with a small, transverse incision, leaving as much atrial tissue attached as possible. Inside the atrium, this incision was extended circumferentially, below the orifices of the inferior pulmonary veins and coronary sinus (CS). The CS cut-back prevented obstruction by subsequent atrial closure. Septal remnants were resected and any intracardiac procedures were performed. Atrial closure parallel to the inferior pulmonary veins optimized space for the inferior caval vein pathway. As this suture line became inaccessible, hemostasis was imperative. (ASD = atrial septal defect.) (D) After removing the air and after aortic unclamping, the atrial cuff was connected end-to-end to the MPA with a fine running absorbable suture (ie, 6-0 or 7-0) interrupted at multiple sites or continuously locked to avoid pursestring narrowing. Because this cuff greatly exceeded the MPA diameter, the anastomosis was often continued along the rightward MPA and (if needed) onto the undersurface of the right pulmonary artery. Finally, the SVC was positioned wherever it was needed on the upper surface of the pulmonary arteries to repair sites of narrowing or previous shunts. Three maneuvers, singly or in combination, resolved inevitable branch pulmonary arterial redundancy: (1) extensive mobilization that permitted lateral displacement, (2) upward incorporation into the SVC connection, or (3) downward displacement into the atrial anastomosis. Alignment of the markers placed before bypass prevented twisting of the vessels.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

3. Fig 2
(A) Representative imaging of pathways by angiography and (B) echocardiography at 6 months and 6 years, respectively, after complete extracardiac Fontan operation at 9.8 kg. (IVC = inferior caval vein; RA = right atrium; RSVC = right superior caval vein.)
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions