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Hraska V, Mitchell ME, Woods RK, Hoffman GM, Kindel SJ, Ginde S. Innominate Vein Turn-down Procedure for Failing Fontan Circulation. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2021; 23:34-40. [PMID: 32354545 DOI: 10.1053/j.pcsu.2020.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 01/06/2020] [Accepted: 01/25/2020] [Indexed: 12/16/2022]
Abstract
After the Fontan, systemic venous hypertension induces pathophysiologic changes in the lymphatic system that can result in complications of pleural effusion, ascites, plastic bronchitis, and protein losing enteropathy. Advances in medical therapy and novel interventional approaches have not substantially improved the poor prognosis of these complications. A more physiological approach has been developed by decompression of the thoracic duct to the lower pressure common atrium with a concomitant increase of preload. Diverting the innominate vein to the common atrium increases the transport capacity of the thoracic duct, which in most patients enters the circulation at the left subclavian-jugular vein junction. Contrary to the fenestrated Fontan circulation, in which the thoracic duct is drained into the high pressure Fontan circulation, turn down of the innominate vein to the common atrium effectively decompresses the thoracic duct to the lower pressure system with "diastolic suctioning" of lymph. Innominate vein turn-down may be considered for medical-refractory post-Fontan lymphatic complications of persistent chylothorax, plastic bronchitis, and protein losing enteropathy. Prophylactic innominate vein turn-down may also be considered at time of the Fontan operation for patients that are higher risk for lymphatic complications.
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Affiliation(s)
- Viktor Hraska
- Division of Congenital Heart Surgery; Department of Surgery, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Michael E Mitchell
- Division of Congenital Heart Surgery; Department of Surgery, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ronald K Woods
- Division of Congenital Heart Surgery; Department of Surgery, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - George M Hoffman
- Department of Anesthesia, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Steven J Kindel
- Division of Pediatric Cardiology, Department of Pediatrics, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Salil Ginde
- Division of Pediatric Cardiology, Department of Pediatrics, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, Wisconsin
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Pundi KN, Pundi K, Driscoll DJ, Dearani JA, Li Z, Dahl SH, Mora BN, O'Leary PW, Daly RC, Cetta F, Johnson JN. Heart transplantation after Fontan: Results from a surgical Fontan cohort. Pediatr Transplant 2016; 20:1087-1092. [PMID: 27397767 DOI: 10.1111/petr.12753] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2016] [Indexed: 01/12/2023]
Abstract
We performed a retrospective review of outcomes after heart transplantation during long-term follow-up of a surgical cohort of 1138 Fontan patients who were followed at the Mayo Clinic. Follow-up information was obtained from medical records and a clinical questionnaire that was mailed to patients not known to be deceased at the initiation of the study. Forty-four of 1138 Fontan patients with initial or subsequent evaluation at Mayo had cardiac transplantation between 1988 and 2014 (mean age at transplantation was 23.2 ± 12 yr, median was 19.8 yr; mean interval between Fontan and transplantation was 13.0 ± 7.7 yr, median was 13.1 yr). Two patients had combined organ transplantation (one heart-lung, one heart-liver). Twelve of the 44 (27%) patients had PLE prior to transplantation. There was no difference in post-bypass Fontan pressures or incidence of late reoperations for AVV repair/replacement between transplanted and non-transplanted patients. There were 16 (36%) deaths in the transplantation cohort; seven occurred within 30 days of transplantation. Overall one, five, 10, and 15 yr post-transplantation survival was 80%, 72%, 69%, and 55%, respectively. Although this is a challenging group of patients, intermediate-term results suggest that cardiac transplantation remains a reasonable option for patients with a failed Fontan circulation.
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Affiliation(s)
- Kavitha N Pundi
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA
| | - Krishna Pundi
- Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - David J Driscoll
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA
| | - Joseph A Dearani
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Zhuo Li
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Sonja H Dahl
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA
| | - Bassem N Mora
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Patrick W O'Leary
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA.,Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Richard C Daly
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Frank Cetta
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA.,Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Jonathan N Johnson
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA.,Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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