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On-pump Fontan versus off-pump Fontan in patients with critical pulmonary status.

We read with great interest the manuscript by Shiraishi et al. [1], in which the authors successfully finalized surgical treatment in a patient with single ventricle physiology and critical pulmonary status. The manuscript lacks detailed information about the surgical procedure. Fontan procedure is the end-stage palliative option for univentricular hearts in the current era. Pulmonary properties are vitally important in this particular patient group. Operations may be performed with or without cardiopulmonary bypass and cross-clamping. It has been shown that extracardiac Fontan without cardiopulmonary bypass and cross-clamping have various advantages on ventricular and pulmonary functions. These include decreased incidence of arrhythmia attenuated usage of inotropic agents and blood/blood products, lesser activation of inflammatory cascades, decreased pleural effusion and earlier extubation [2-4]. Although adhesions after several cardiac procedures in the mediastinum of the patient presented by the authors may be expected and complicate further cardiac procedures, we believe off-pump Fontan completion might have been a good option for such patients with deteriorated pulmonary functions. 
 
Conflict of interest: none declared.