Original article
Pediatric cardiac
Can the Kawashima Procedure Be Performed in Younger Patients?

Presented at the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.
https://doi.org/10.1016/j.athoracsur.2009.04.045Get rights and content

Background

The prudence of performing early palliative cavopulmonary connection that includes superior vena cava in association with azygous-hemiazygous continuation of the inferior vena cava, Kawashima procedure (KP), has been questioned. We document our experience with KP performed at a relatively younger age than usually reported.

Methods

A retrospective review of patients undergoing KP (October 2000 to April 2008) was done.

Results

Initial palliation was carried out in 13 of 15 patients. Age and weight at KP was 8.4 months (5.1 to 15.1) and 6.8 kg (4.6 to 11.0). The pre-KP catheterization showed the following: pulmonary artery pressure = 14.5 mm Hg (9 to 17); end-diastolic pressure of systemic ventricle = 8 (2 to 14); oxygenation saturation = 76% (63 to 82); and atrioventricular (AV) valve insufficiency moderate or greater in 5 patients. The post-KP characteristics included the following intubation = 1 day (0 to 19); nitric oxide = 4 patients; superior caval pressure = 14 mm Hg (6 to 18); inotrope score = 7.5 (2.5 to 14.3); intensive care unit stay = 3 days (1 to 9); hospital stay = 7 days (3 to 77); and oxygen saturation at discharge = 84% (76 to 90%). There was one hospital death that required takedown of KP. Fontan completion was performed in 8 patients at an interval of 2.7 years (1.8 to 5.8) after KP. There was one post-Fontan mortality from severe ventricular and AV valve dysfunction. Pulmonary arteriovenous malformations (PAVMs) were diagnosed in 4 patients with 3 resolving post-Fontan. With a median follow-up of 4.2 years (0.1 to 7.9), 13 of 15 remain alive yielding a series survival of 87%.

Conclusions

The Kawashima procedure can be safely performed at an earlier age than previously reported. The incidence of PAVMs after the KP appears to be similar to other reports where KP was performed at a later age.

Section snippets

Demographics

A retrospective review of all patients less than 18 years of age undergoing a Kawashima procedure at Childrens Hospital Los Angeles from October 2000 to April 2008 was performed. Both inpatient and outpatient charts were reviewed following guidelines established by the Institutional Review Board. Demographic data regarding gender, cardiac morphology, presence of asplenia-polysplenia (based on spleen scan), and bilateral SVC and initial surgical palliation were tabulated.

Operative Description

Preoperative data

Demographics

Among the 15 patients that met criteria, 11 were male. All patients had heterotaxy and an unbalanced AV septal defect. Additional cardiology morphology for each patient is detailed in Table 1. Data with respect to splenic abnormalities, presence of bilateral SVC, and side of azygous continuation are shown in Table 1. As detailed in Table 1, 13 of 15 patients underwent initial palliation prior to KP. Of the 6 patients who underwent Blalock-Taussig (BT) shunt placement with restriction of

Appropriate Age for Kawashima

Many centers have demonstrated that the Kawashima procedure can be performed safely in patients who are more than 1 year of age [2, 3, 7]. A recent series from Indiana documented 21 patients undergoing their KP at a median age of 2 years and a median weight of 11.2 kg [2]. Similarly, in a large series from Boston, 36 patients underwent KP with one cohort of 16 patients (who subsequently developed post-KP PAVMs) undergoing their procedure at a median age of 10 months, while a second cohort with

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