Reply to Goksel and Tireli

We would like to thank Goksel and Tireli for their recent comments [1] on our recently published article [2]. We do not have any experience with off-pump surgery for cavopulmonary shunt or Fontan completion. This technique certainly has attractions of avoiding the potential deleterious effects of cardiopulmonary bypass as highlighted, particularly in terms of pulmonary vascular resistance and inflammatory response. It would be interesting to know the exact impact on the amount and duration of pleural drainage. Our greatest concernwith the off-pump technique is that is does not really allow for any reconstruction or plasty of the pulmonary arteries, which frequently needs addressing at the time of surgery, particularly following the Norwood procedure. We prefer a bypass approach which is close to normothermia on the beating heart and feel this allows for accurate assessment of the PAs and where necessary augmentation and reconstruction. It also guarantees maintenance of cardiac output should there be problems with bleeding or accessing the IVC. We await further evidence to evaluate the benefits and risks of offpump Fontan surgery.