An alternative idea to an alternative technique

We read with interest the article by Federici et al. [1]. Scimitar syndrome is a rare congenital heart disease characterized by a wide spectrum of lesions linked to the anomalous right pulmonary venous drainage and to the degree of the right lung hypoplasia. A multicentric study done in Italy has reported on 27 patients over a 10-year span in less than 10 paediatric cardiology centres [2]. These data mean a very small individual surgical experience, and overall results are non conclusive '. large enough for drawing any statistical conclusion.', as these authors eventually stated [1]. As a matter of fact, both surgical techniques and planning of extracorporeal circulation strategies have been quite different as they strongly stimulate medical imagination. To allow a precise evaluation of this alternative approach, we need more details. Connecting the inferior vena cava (IVC) drainage to a vacuum (-60mmHg)- assisted reservoir is a good idea. This choice allows the use of a small-sized cannula (20 Fr in this report). As reported in the US patent by Cambron et al. [3], the usual negative pressure employed is -5/-35mmHg. This is also greater than the one employed in a more recent report [4]. The amount of blood cell trauma could be significant because of strong suction and it is then mandatory to report the values of blood laboratory screen tests for haemolysis [5]. The prolonged and heavy contact between blood and air is another concern. An alternative idea to the aforementioned problem is to place a long venous cannula (such as one for port access cardiac surgery) positioned via the right femoral vein into the IVC, just at the level of the right cavoiliac junction. In such a way, the main blood drainage from the IVC is directed towards this cannula. A small pump sucker is usually good enough to get a clear operative field during the proper placement of stitches inside the IVC, provided it does not suck too deeply into the abdomen.