Dear Sir,

On behalf of my co-authors, I should like to thank Drs Ebels and Waterbolk for pointing out that, in 1995, they had described a case of intrahepatic right-to-left shunting after the Fontan procedure in a fairly similar situation to the one we emphasised in our recent brief report. The point we wanted to make is that, having confirmed the presence of large intrahepatic collaterals, one can safely ligate one hepatic vein. To band one hepatic vein solves only part of the problem. Furthermore, it is very difficult to apply any form of scientific criterions when deciding how to band a vein.

It is important not to confuse persistent right-to-left shunt following the Kawashima procedure with the shunt described by Drs Ebels and Waterbolk. In the Kawashima procedure, all the hepatic veins drain to the same low pressure atrial chamber. Incidentally, I believe that Dr Yves Lecompte from Paris was the first surgeon to suggest sequestrating part of the hepatic venous return to the right atrium during the Fontan procedure so as to unload the Fontan pathway. This was then applied by Dr Norwood and his colleagues, and abandoned because of the occurrence of increasing right-to-left shunt through these intrahepatic collateral vessels.