Hepatic vein to Azygos vein Connection in a Patient with Left Isomerism
Elisabeth Martin, Osami Honjo.
Sick Kids Hospital, toronto, ON, Canada.
Objectives: Patients with left isomerism, interrupted inferior vena cava and single ventricle physiology often develop pulmonary arterio-venous malformations (AVMs) following the Kawashima operation which causes intrapulmonary right-to-left shunt. Rerouting the hepatic venous blood flow to the pulmonary circulation by means of Fontan operation is essential to prevent AVMs. Nonetheless, the conventional Fontan operation may not provide balanced distribution of the hepatic factor to both lungs due to competitive flow from the Kawashima anastomosis.
Methods: We report a case where the hepatic vein was rerouted to the azygous vein with the use of a polytetrafluoroethylene (PTFE) tube graft through a median sternotomy in a patient with left atrial isomerism, interrupted IVC with azygous continuation who previously underwent right-sided Kawashima operation.
Results: After redo sternotomy and establishment of normothermic cardiopulmonary bypass, the hepatic vein was divided at the junction to the right atrium, and the posterior pericardium directly posterior to the hepatic vein and the right atrium was open to expose the right sided azygos vein. An end-to-side anastomosis was made between the 14mm PTFE graft and the azygos vein, followed by an end-to-end anastomosis between the graft and the hepatic vein. There was no flow acceleration through the hepatic-azygos pathway on the postoperative echocardiogram.
Conclusions: When anatomically feasible, hepatic vein to azygous vein connection would be a viable alternative to the conventional Fontan operation and can be performed through a median sternotomy.
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