The Off-Pump Fontan Procedure by Simply Cross-Clamping the Inferior Caval Vein

Background We previously used the Fontan procedure, when applicable, by placing a temporary bypass from the inferior vena cava to the atrium. Alternatively, we have striven to achieve the procedure even without use of a temporary bypass in patients having collaterals between the inferior vena cava and the superior vena cava, so as to simplify the procedure. The azygous vein was intentionally left patent at the bidirectional Glenn procedure in the most recent 9 patients, expecting reasonable venovenous communication at Fontan completion. Surgical results will be described for the preliminary experience. Methods Since 2001, this alternative technique has been attempted in 34 patients undergoing the staged Fontan procedure, and eventually used in 22. Duration between the staged procedures was 4 to 108 months (median, 10 months). We considered that the technique was feasible unless femoral venous pressure exceeded 20 mm Hg immediately after cross-clamping the inferior vena cava. Although catheterization before the Fontan completion illustrated development of venovenous collaterals in 14 patients, oxygen saturation remained greater than 80% throughout the period of the bidirectional Glenn physiology. Results In all 22 patients, the extracardiac channel was readily reconstructed with an excellent surgical field of view, without operative mortality. On cross-clamping the inferior vena cava, the systemic circulation could be well maintained by administration of dopamine. Oxygen saturation immediately became approximately 97% to 100%. Maximal pressure gradient was 11 ± 5 mm Hg between the superior vena cava and the femoral vein. Postoperatively, serum concentration of enzymes did not critically increase (maximal aspartate transaminase, 96 ± 89 U/L; alanine transaminase, 65 ± 59 U/L; total bilirubin, 1.8 ± 1.1 mg/dL; creatine kinase, 437 ± 230 U/L). Conclusions This alternative technique, when feasible under the current criteria, was simple and did not provide any clinically significant impediments.