Commentary: Innominate turndown—a better insurance for the Fontan circulation?

Abstract

Protein-losing enteropathy and plastic bronchitis are significant complications of Fontan circulation. Although protein-losing enteropathy or plastic bronchitis develops in up to 5% of Fontan patients, these complications can lead to circulatory failure or death in almost a one-third of the patients with these complications. In their article in this issue of JTCVS Techniques, Hraska and coauthors not only demonstrate the lymphatic pathophysiology behind these severe complications, but also present the techniques and outcomes of a surgical remedy in the form of innominate vein turndown procedure. Out of 14 patients who underwent innominate vein turndown procedure presented in this series, 2 underwent the procedure concomitantly with Fontan completion and 12 did so after the development of Fontan failure. After a follow-up of 3 to 36months, there were 3 deaths in the series, all in patients with end-stage Fontan failure. Almost one-third of the survivors developed either narrowing at the innominate vein atrial anastomosis or thrombosis and required percutaneous reintervention on the pathway. In addition to innominate vein turndown and direct anastomosis, the authors also describe the use of a ring-supported expanded polytetrafluoroethylene tube as an interposition graft to allow a tension-free innominate vein-to-atrial connection using the “dunked” technique, which may reduce the anastomotic reintervention rate and even allow performance of the procedure without cardiopulmonary bypass. Additional