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Right-Thoracotomy, Off-Pump Clamp-and-Sew Bidirectional Glenn
*Corresponding author: Khaled Ebrahim Al-Ebrahim, Department of Surgery, King Abdulaziz University, Jeddah, Saudi Arabia. dr.k.ebrahim@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Al-Ebrahim KE. Right-Thoracotomy, Off-Pump Clamp-and-Sew Bidirectional Glenn. J Card Crit Care TSS. doi: 10.25259/JCCC_58_2025
Dear Editor,
I read with interest the article by Murtaza et al.,[1] “Operative Steps for Bidirectional Glenn Procedure: A Guide for Beginners (With a Small Modification).” The authors present a clear, useful stepwise description that will benefit trainees; I congratulate them on an educational and practical contribution.[1] I wish to add a complementary technical option we have used at our center that was not discussed in the manuscript: Performing the bidirectional Glenn through a right anterior thoracotomy and completing the superior vena cava-right pulmonary artery (SVC-RPA) anastomosis without routine cardiopulmonary bypass or a shunt, relying instead on meticulous vessel preparation and a short, head-up, rapid clamp-and-sew anastomosis. The key points of our approach are:
Patient selection: Suitable for patients with favorable anatomy (adequate RPA size, no need for simultaneous intracardiac repair) and acceptable baseline pulmonary pressures.
Exposure: Right anterior thoracotomy at the fourth interspace provides direct access to the SVC and RPA while avoiding a median sternotomy and its future adhesions, saving it for future procedures.
Preparation: Systemic heparinization, thorough mobilization of the SVC and RPA, proximal and distal vascular control, and temporary lowering of SVC pressure using head-up positioning and controlled venous drainage.
Anastomosis: After full preparation, division of SVC between clamps, a rapid end-to-side SVC-RPA anastomosis is performed with short clamping time (team coordination is essential) using 5 or 6 -0 Prolene (polypropylene), unclamp RPA and proximal SVC, oversewing distal end of SVC.
Advantages observed in our series include preservation of the median sternotomy for future Fontan completion, less mediastinal dissection and blood loss, and shorter operative time in selected patients. Caveats include strict patient selection and the need for an experienced team. Neurological monitoring and short SVC clamp times are essential to minimize cerebral risk. I thank the authors for their instructive contribution and offer this technique as an alternative in carefully selected patients; incorporation of such options in descriptive surgical guides helps broaden the trainee’s armamentarium.[2-4]
Table 1 shows comparison between two techniques.
| Aspect | Thoracotomy off-pump Glenn (our technique) | Conventional median sternotomy/CPB-assisted Glenn |
|---|---|---|
| Patient selection | Favorable anatomy, adequate RPA size, no intracardiac repair needed, acceptable PVR | Broad indications; suitable when intracardiac work or complex anatomy requires CPB |
| Key procedural features | Right anterior thoracotomy; full SVC/RPA mobilization; head-up position; rapid clamp-and-sew SVC-RPA anastomosis without CPB or shunt | Median sternotomy; CPB or shunt commonly used; longer dissection and cannulation steps |
| Outcomes/Pros and Cons | Shorter op time, less blood loss, preserves sternotomy for future Fontan; requires strict selection and experienced team | More controlled hemodynamics, wider applicability, higher invasiveness, and adhesions for future surgeries |
CPB: Cardiopulmonary bypass, SVC: Superior vena cava, RPA: Right pulmonary artery, PVR: Pulmonary vascular resistance
Ethical approval:
Institutional Review Board approval is not required.
Declaration of patient consent:
Patient’s consent not required as there are no patients in this study.
Conflict of interest:
There are no conflict of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The author confirms that he has used ChatGPT for grammar and to ease readability.
Financial support and sponsorship: Nil.
References
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