Congenital Heart Surgery

Kawashima Procedure: The Impact of Age. Ivanov Y, Buratto E, Ishigami S, Chowdhuri KR, Schulz A, Brizard CP, Konstantinov IE.Ann Thorac Surg. 2023 Aug;116(2):366-372. doi: 10.1016/j.athoracsur.2022.10.015. Epub 2022 Oct 23.PMID: 36288759 Take Home Points: Kawashima operation can be performed with low operative risk and acceptable long-term outcomes CAVV procedure carries a risk for mortality. Commentary from Dr. Masamichi Ono (Munich, Germany), section editor of Congenital Heart Surgery Journal Watch:  This retrospective, single-center study looked at surgical outcomes of patients who underwent the Kawashima procedure from March 1990 to November 2020 at Royal Children´s Hospital, Melbourne Australia. Thirty patients underwent Kawashima procedure at a median age of 11.7 months (IQR, 4.4-27.4) and a median weight of 8.1 kg (IQR, 5.3-11). Concomitant procedures were done in 13 (43.3%) of 30 patients. Six patients (20%) had antegrade flow after the Kawashima procedure; in 4 of them, it was left intact; 1 patient underwent partial main pulmonary artery closure; another patient underwent tightening of pulmonary artery band. Early mortality was 0%. There were 2 take-downs. Median follow-up was 9.7 years (range, 2 months to 25.8 years). In 53%(n=16), pulmonary arteriovenous malformation (PAVM) developed in a mean time of 3.6 ± 2.4 years after Kawashima procedure; in all these patients, antegrade pulmonary blood flow was absent. Fontan completion was achieved in 25 of 30 patients (86.2%) at a median time of 3.6 years (IQR, 2.5-6.6) after Kawashima. There were 2 deaths (6.8%) after Kawashima procedure but before Fontan completion. Both patients needed AV valve replacement and died of heart failure. Overall freedom from death and transplantation at 5,10, and 20 years after Kawashima was 93.2%, 89.5%, and 67% respectively. Freedom from death and transplantation at 10 years was 100% for children 3 to 6 months of age at the time of Kawashima. During a median follow-up of 9.7 years, patients (23 - 88.5%) were in New York Heart Association functional class I-II; 2 patients (7.7%) were in functional class III; 1 patient (3.8%) was in functional class IV. Comment: This single-center study included 30 patients who underwent Kawashima at a median age of 11.7 months (IQR, 4.4-27.4). In this cohort, 90% of the patients were associated with left isomerisms and 77% had Common Atrioventricular valve (CAVV). Five patients needed CAVV repair at the time of Kawashima, and 2 patients who needed take-down after Kawashima needed AVV replacement. Overall freedom from death and transplantation among patients who underwent AVV repair concomitant to Kawashima procedure was worse than those who did not (p=0.04). Two patients needed a Fontan revision because of the development of PAVM. The Kawashima procedure is indicated for patients with functional single ventricles and azygos/hemi-azygos continuation. This pathology is frequently associated with heterotaxy syndrome UAVSD, bilateral SVC, and DORV. Problematic complications included the progression of CAVV regurgitation after the initial systemic-to-pulmonary shunt was problematic before and after the Kawashima procedure as well as the development of PAVM after the Kawashima procedure. This paper suggests that early Kawashima procedure between 3 to 6 months of age had better results. A longer duration of shunt-dependent physiology might increase the degree of CAVV and trigger systemic ventricular dysfunction. To preserve the systemic ventricular function, early Kawashima procedure is recommended. As patients after Kawashima procedure frequently develop PAVM, early Fontan completion is also recommended. Fontan completion in this study was at a median of 3.6 years. It is younger than previous studies. Many centers now agree that Kawashima procedure can safely be performed in infants. Fontan completion at 2-3 years old might be an optimal strategy. As for the ante-grade PBF, we adopted the strategy of closure of all ante-grade flow at the time of Kawashima and performing swift Fontan completion. It might be better to leave some ante-grade flow if patients have risks for early Fontan completion.