Hostname: page-component-cd9895bd7-p9bg8 Total loading time: 0 Render date: 2024-12-30T23:34:54.686Z Has data issue: false hasContentIssue false
  • English
  • Français

Can we do without routine fenestration in extracardiac total cavopulmonary connections? Report on 84 consecutive patients

Published online by Cambridge University Press:  03 February 2006

Christian Schreiber ,
Martin Kostolny ,
Jürgen Hörer ,
Julie Cleuziou ,
Klaus Holper ,
P. Tassani-Prell ,
Andreas Eicken  and
Rüdiger Lange
Christian Schreiber
Affiliation:
Clinic of Cardiovascular Surgery, German Heart Centre Munich at the Technical University, Munich, Germany
Martin Kostolny
Affiliation:
Clinic of Cardiovascular Surgery, German Heart Centre Munich at the Technical University, Munich, Germany
Jürgen Hörer
Affiliation:
Clinic of Cardiovascular Surgery, German Heart Centre Munich at the Technical University, Munich, Germany
Julie Cleuziou
Affiliation:
Clinic of Cardiovascular Surgery, German Heart Centre Munich at the Technical University, Munich, Germany
Klaus Holper
Affiliation:
Clinic of Cardiovascular Surgery, German Heart Centre Munich at the Technical University, Munich, Germany
P. Tassani-Prell
Affiliation:
Department of Anesthesiology, German Heart Centre Munich at the Technical University, Munich, Germany
Andreas Eicken
Affiliation:
Department of Paediatric Cardiology and Congenital Cardiac Diseases, German Heart Centre Munich at the Technical University, Munich, Germany
Rüdiger Lange
Affiliation:
Clinic of Cardiovascular Surgery, German Heart Centre Munich at the Technical University, Munich, Germany
Get access Rights & Permissions [Opens in a new window]

Abstract

Fenestration is still widely used in right heart bypass operations. Our study was conducted to assess its need in the most recent modification, the completion of a total cavopulmonary connection with an extracardiac tube.

The extracardiac approach was introduced at our institution in January, 1999. Since June of 2000, no patient had a fenestration. If more than 1 risk factor amongst ventricular function being more than moderately impaired, atrioventricular valvar regurgitation more than moderate, mean pulmonary arterial pressure more than 15 millimetres of mercury, mean atrial pressure higher than 12 millimetres of mercury, pulmonary arterial distortion, or other than sinus rhythm was present preoperatively, the patient was considered a “high risk” candidate. Postoperatively elevated pulmonary arterial pressure higher than 16 millimetres of mercury, prolonged effusions and requirement for drainage longer than 7 days, and death were considered endpoints in the statistical analysis.

Our study group included 84 patients who underwent surgery up to August, 2004. A previous bidirectional cavopulmonary anastomosis had been accomplished in 73 patients at a mean age of 27.01 plus or minus 32.60 months, with a median of 11.5 months, without creating an additional source of flow of blood to the lungs.

At the time of the total cavopulmonary connection, the mean age was 66.4 plus or minus 60.1 months, with a median of 37.1 months, and a range from 17.3 to 251.2 months, with 50 patients being younger than 48 months.

We deemed 16 patients to be at “high risk”. These patients were older at the time of bidirectional cavopulmonary anstomosis (p smaller than 0.016), at the time of completion (p smaller than 0.019), and also differed in size at time of completion (p smaller than 0.020). They required a longer time on cardiopulmonary bypass (p smaller than 0.015), and reached higher early postoperative pulmonary arterial pressures after completion (p smaller than 0.025). There were no differences between groups of patients having up to 1 or more risk factors in regard to need for intubation (p smaller than 0.511), pulmonary arterial pressures after extubation (p smaller than 0.817), and duration of chest drainage (p smaller than 0.650). Three patients died, one in the group deemed at high risk. There was no death in the last 38 patients.

We conclude that a total cavopulmonary connection with an extracardiac tube can be performed without fenestration, even if the patients are deemed to be at increased risk. Early staging of patients with functionally univentricular physiology might be one of the keys for these findings.

Keywords

Total cavopulmonary connectionFontan procedurefunctionally univentricular heart
Type
Original Article
Information
Cardiology in the Young , Volume 16 , Issue 1 , January 2006 , pp. 54 - 60
Copyright
© 2006 Cambridge University Press

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Schreiber C, Kostolny M, Weipert J, et al. What was the impact of the introduction of extracardiac completion for a single center performing total cavopulmonary connections? Cardiol Young 2004; 14: 140–147.Google Scholar
Tokunaga S, Kado H, Imoto Y, et al. Total cavopulmonary connection with an extracardiac conduit: experience with 100 patients. Ann Thorac Surg 2002; 73: 76–80.Google Scholar
Van Haesdonck JM, Mertens L, Sizaire R, et al. Comparison by computerized numeric modeling of energy losses in different Fontan connections. Circulation 1995; 92: II322–II326.Google Scholar
de Leval MR, Dubini G, Migliavacca F, et al. Use of computational fluid dynamics in the design of surgical procedures: application to the study of competitive flows in cavopulmonary connections. J Thorac Cardiovasc Surg 1996; 111: 502–513.Google Scholar
Azakie A, McCrindle BW, Van Arsdell G, et al. Extracardiac conduit versus lateral tunnel cavopulmonary connections at a single institution: impact on outcomes. J Thorac Cardiovasc Surg 2001; 122: 1219–1228.Google Scholar
Alexi-Meskishvili V, Ovroutski S, Ewert P, et al. Mid-term follow-up after extracardiac Fontan operation. Thorac Cardiovasc Surg 2004; 4: 218–224.Google Scholar
Billingsley AM, Laks H, Boyce SW, George B, Santulli T, Williams RG. Definitive repair in patients with pulmonary atresia and intact ventricular septum. J Thorac Cardiovasc Surg 1989; 97: 746–754.Google Scholar
Bridges ND, Lock JE, Castaneda AR. Baffle fenestration with subsequent transcatheter closure. Modification of the Fontan operation for patients at increased risk. Circulation 1990; 82: 1681–1689.Google Scholar
Bridges ND, Jonas RA, Mayer JE, Flanagan MF, Keane JF, Castaneda AR. Bidirectional cavopulmonary anastomosis as interim palliation for high-risk Fontan candidates: early results. Circulation 1990; 82 (Suppl IV): IV170–IV176.Google Scholar
Laks H, Pearl JM, Haas GS, et al. Advantages of an adjustable interatrial communication. Ann Thorac Surg 1991; 52: 1084–1094.Google Scholar
Bridges ND, Mayer Jr JE, Lock JE, et al. Effect of baffle fenestration on outcome of the modified Fontan operation. Circulation 1992; 86: 1762–1769.Google Scholar
Mavroudis C, Zales VR, Backer CL, Muster AJ, Latson LA. Fenestrated Fontan with delayed catheter closure: effects of volume loading and baffle fenestration on cardiac index and oxygen delivery. Circulation 1992; 86 (Suppl): 85–92.Google Scholar
Kopf GS, Kleinman CS, Hijazi ZM, Fahey JT, Dewar ML, Hellenbrand WE. Fenestrated Fontan operation with delayed transcatheter closure of atrial septal defect: improved results in high-risk patients. J Thorac Cardiovasc Surg 1992; 103: 1039–1047.Google Scholar
Gentles TL, Mayer Jr JE, Gauvreau K, et al. Fontan operation in five hundred consecutive patients: factors influencing early and late outcome. J Thorac Cardiovasc Surg 1997; 114: 376–391.Google Scholar
Gentles TL, Gauvreau K, Mayer Jr JE, et al. Functional outcome after the Fontan operation: factors influencing late morbidity. J Thorac Cardiovasc Surg 1997; 114: 392–403.Google Scholar
Cochrane AD, Brizard CP, Penny DJ, et al. Management of the univentricular connection: are we improving? Eur J Cardiothorac Surg. 1997; 12: 107–115.Google Scholar
Bando K, Turrentine MW, Park HJ, Sharp TG, Scavo V, Brown JW. Evolution of the Fontan procedure in a single center. Ann Thorac Surg 2000; 69: 1873–1879.Google Scholar
Gaynor JW, Bridges ND, Cohen MI, et al. Predictors of outcome after the Fontan operation: is hypoplastic left heart syndrome still a risk factor? J Thorac Cardiovasc Surg 2002; 123: 237–245.Google Scholar
Kumar SP, Rubinstein CS, Simsic JM, Taylor AB, Saul JP, Bradley SM. Lateral tunnel versus extracardiac conduit Fontan procedure: a concurrent comparison. Ann Thorac Surg 2003; 76: 1389–1396.Google Scholar
McGuirk SP, Winlaw DS, Langley SM, et al. The impact of ventricular morphology on midterm outcome following completion total cavopulmonary connection. Eur J Cardiothorac Surg 2003; 24: 37–46.Google Scholar
Gupta A, Daggett C, Behera S, Ferraro M, Wells W, Starnes V. Risk factors for persistent pleural effusions after the extracardiac Fontan procedure. J Thorac Cardiovasc Surg 2004; 127: 1664–1669.Google Scholar
Hsu DT, Quaegebeur JM, Ing FF, Selber EJ, Lamour JM, Gersony WM. Outcome after the single-stage, nonfenestrated Fontan procedure. Circulation 1997; 96 (Suppl II): II335–II340.Google Scholar
Thompson LD, Petrossian E, McElhinney DB, et al. Is it necessary to routinely fenestrate an extracardiac fontan? J Am Coll Cardiol 1999; 34: 539–544.Google Scholar
Airan B, Sharma R, Choudhary SK, et al. Univentricular repair: is routine fenestration justified? Ann Thorac Surg 2000; 69: 1900–1906.Google Scholar
du Plessis AJ, Chang AC, Wessel DL, et al. Cerebrovascular accidents following the Fontan operation. Pediatr Neurol 1995; 12: 230–236.Google Scholar
Cetta F, Feldt RH, O'Leary PW, et al. Improved early morbidity and mortality after Fontan operation: the Mayo Clinic experience, 1987 to 1992. J Am Coll Cardiol 1996; 28: 480–486.Google Scholar
Jahangiri M, Ross DB, Redington AN, Lincoln C, Shinebourne EA. Thromboembolism after the Fontan procedure and its modifications. Ann Thorac Surg 1994; 58: 1409–1413.Google Scholar
Rosenthal DN, Friedman AH, Kleinman CS, Kopf GS, Rosenfeld LE, Hellenbrand WE. Thromboembolic complications after Fontan operations. Circulation 1995; 92 (Suppl): 287–293.Google Scholar
Lemler MS, Scott WA, Leonard SR, Stromberg D, Ramaciotti C. Fenestration improves clinical outcome of the fontan procedure: a prospective, randomized study. Circulation 2002; 105: 207–212.Google Scholar
Jacobs ML, Norwood Jr WI, Fontan operation: influence of modifications on morbidity and mortality. Ann Thorac Surg 1994; 58: 945–951.Google Scholar
Fedderly RT, Whitstone BN, Frisbee SJ, Tweddell JS, Litwin SB. Factors related to pleural effusions after Fontan procedure in the era of fenestration. Circulation 2001; 104: I148–I151.Google Scholar
de Leval MR. The Fontan circulation: What have we learned? What to expect? Pediatr Cardiol 1998; 19: 316–320.Google Scholar
Koutlas TC, Gaynor JW, Nicolson SC, et al. Modified ultrafiltration reduces postoperative morbidity after cavopulmonary connection. Ann Thorac Surg 1997; 64: 37–42.Google Scholar
Amodeo A, Galletti L, Marianeschi S, et al. Extracardiac Fontan operation for complex cardiac anomalies: seven years' experience. J Thorac Cardiovasc Surg 1997; 114: 1020–1031.Google Scholar
Uemura H, Yagihara T, Kawahira Y, Yoshikawa Y, Kitamura S. Total cavopulmonary connection in children with body weight less than 10 kilogram. Eur J Cardiothorac Surg 2000; 17: 543–549.Google Scholar