tive right ventricle below the attachment of the valve or the right ventricle with the atrialized right ventricle? In most of the patients on whom my own group has op- erated, the right anterior wall was dilated and hypokinetic. 4 I am interested to know whether this aspect was present in Chen and colleagues’ series. 1 The postoperative decrease of right ven- tricular ejection fraction could be due to the section of abnormal muscular trabecula- tions. It is in my mind an additional reason to decrease the preload of the right ventri- cle with a partial Glenn procedure. Sylvain Chauvaud, MD Department of Cardio-Vascular Surgery Hôpital Européen Georges Pompidou 20 rue Leblanc 75015 Paris, France References 1. Chen JM, Mosca RS, Altmann K, Printz BF, Targoff K, Mazzeo PA, et al. Early and me- dium-term results for repair of Ebstein anom- aly. J Thorac Cardiovasc Surg. 2004;127: 990-9. 2. Celermajer DS, Bull C, Till JA, Cullen S, Vassillikos V, Sullivan ID, et al. Ebstein’s anomaly: presentation and outcome from fe- tus to adult. J Am Coll Cardiol. 1994;23: 170-6. 3. Chauvaud S, Fuzellier JF, Berrebi A, Lajos P, Marino JP, Mihaileanu S, et al. Bi-directional cavopulmonary shunt associated with ventri- culo and valvuloplasty in Ebstein’s anomaly: benefits in high risk patients. Eur J Cardio- thorac Surg. 1998;13:514-9. 4. Chauvaud S, Berrebi A, d’Attellis N, Mous- seaux E, Hernigou A, Carpentier A. Ebstein’s anomaly: repair based on functional analysis. Eur J Cardiothorac Surg. 2003;23:525-31. doi:10.1016/j.jtcvs.2004.06.041 Reply to the Editor: My coauthors and I are in agreement with Dr Chauvaud’s impression that the Ebstein anomaly is a combination of ventricular and valvular disease. In our study, the right ventricle, as analyzed by transthoracic echocardiography, was considered to be the effective right ventricle below the at- tachment of the valve. In several patients— most notably the adults—the right anterior wall was indeed hypokinetic. Care cer- tainly must be taken not to assign hypoki- netic areas of atrialized ventricle to the true right ventricle. We have not routinely used a Glenn cavopulmonary shunt in our Eb- stein repair, but we recognize it as a viable strategy in those patients for whom reduc- tion in right-sided volume loading may be beneficial. Jonathan M. Chen, MD Pediatric Cardiac Surgery Columbia University College of Physicians and Surgeons New York, NY 10032 doi:10.1016/j.jtcvs.2004.06.042 Pleural effusion and off-pump Fontan procedure To the Editor: We read with great interest the study by Gupta and colleagues 1 “Risk Factors for Persistent Pleural Effusions After the Ex- tracardiac Fontan Procedure,” published in the June 2004 issue. Prolonged and exces- sive pleural drainage after the Fontan pro- cedure is still the subject of debate. In their series of 100 patients, Gupta and col- leagues 1 reported prolonged duration of pleural drainage in 37% and increased vol- ume of pleural drainage in 30% after the extracardiac Fontan operation. 1 Lower pre- operative oxygen saturation, presence of postoperative infection, smaller graft size, and longer cardiopulmonary bypass time were significantly associated with pro- longed and increased pleural drainage. We have used an off-pump technique for the bidirectional Glenn shunt and the extracardiac Fontan operation in patients without intracardiac anomalies. 2,3 Pro- longed pleural effusion was seen in 2 of 30 patients undergoing the bidirectional Glenn shunt (6.6%). Among 10 patients undergo- ing the off-pump extracardiac Fontan op- eration, only 1 (10%) had pleural drainage for longer than 2 weeks. Lower preoperative oxygen saturation and increased preoperative pulmonary ar- terial pressure may be consequences of in- creased pulmonary vascular resistance. We surmise that cardiopulmonary bypass causes prolonged and excessive pleural ef- fusion with increase of pulmonary vascular resistance and pulmonary arterial pressure. In patients with cyanosis, the blood flow of the major aortopulmonary collateral arter- ies may increase during cardiopulmonary bypass, which causes prolonged pleural ef- fusion in some patients. In conclusion, cardiopulmonary bypass is significantly associated with increased volume of pleural drainage after both the Glenn shunt and the extracardiac Fontan procedure. We believe that pleural drain- age will decrease with the use of an off- pump technique. [Response declined] Ali Kubilay Korkut, MD Gurkan Cetin, MD Ilksen Soyler, MD Emin Tireli, MD Department of Cardiovascular Surgery Istanbul University Istanbul, Turkey References 1. Gupta A, Daggett C, Behera S, Ferraro M, Wells W, Starnes V. Risk factors for persis- tent pleural effusions after the extracardiac Fontan procedure. J Thorac Cardiovasc Surg. 2004;127:1664-9. 2. Tireli E, Basaran M, Kafali E, Harmandar B, Camci E, Dayioglu E, et al. Perioperative comparison of different transient external shunt techniques in bidirectional cavo-pul- monary shunt. Eur J Cardiothorac Surg. 2003;23:518-24. 3. Tireli E. Extracardiac Fontan operation without cardiopulmonary bypass: how to perform the anastomosis between inferior vena cava and conduit. Cardiovasc Surg. 2003;11:225-7. doi:10.1016/j.jtcvs.2004.06.044 The difference is meaningful: Anatomic coronary-coronary bypass or physiologic coronary-coronary bypass? To the Editor: It was with great interest that I read the com- munication of Nežic ´ and colleagues. 1 The authors have renewed interest in coronary- coronary bypass (CCB) grafting by high- lighting its complementary technical issues, especially in the setting of multiple left ante- rior descending artery (LAD) stenosis, which might require a synchronous multisided re- vascularization. The authors have advanced the presumed physiologic advantages related to CCB, aiming thereby to promote their cur- rent surgical alternative. However, the cur- rent case points out the vigilance that should be paid in distinguishing anatomic CCB from physiologic CCB. The physiologic advantage of CCB has been highlighted by Biglioli and associates. 2 However, these authors have imputed this physiologic advantage directly to the dia- stolic coronary flow rather than to its systolic fraction. Biglioli and associates used the ini- tial portion of the right coronary artery as a donor site for the saphenous graft proximal anastomosis providing the LAD. From a physiologic point of view, Biglioli and asso- Letters to the Editor The Journal of Thoracic and Cardiovascular Surgery ● Volume 128, Number 5 799