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Schafstedde M, Nordmeyer S, Schleiger A, Nordmeyer J, Berger F, Kramer P, Ovroutski S. Persisting and reoccurring cyanosis after Fontan operation is associated with increased late mortality. Eur J Cardiothorac Surg 2021; 61:54-61. [PMID: 34195822 DOI: 10.1093/ejcts/ezab298] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 04/22/2021] [Accepted: 05/13/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES The Fontan operation aims at reducing cyanosis and cardiac volume overload in patients with complex univentricular heart malformations. However, persisting or reoccurring cyanosis is frequently observed. We sought to systematically determine the prevalence and clinical consequences of persisting and secondary cyanosis after Fontan operation. METHODS A total of 331 Fontan patients, operated between 1984 and 2016 with a median postoperative follow-up of 7.9 (interquartile range 2.6-15.8) years, were studied retrospectively. Cyanosis was defined as transcutaneous oxygen saturation ≤93% at rest measured by pulse oximetry. Prevalence of cyanosis was analysed at 3 different time points (t1 = post-Fontan operation, t2 = post-Fontan cardiac catheterization, t3 = last follow-up) and the association of cyanosis with mortality was examined. RESULTS Prevalence of cyanosis was 50% at t1 and 39% at t3. Fenestration was patent in 71% and 33% of all cyanotic patients at t1 and t3, respectively. In patients with clinical indication for catheterization (t2; n = 178/331), prevalence of cyanosis was 72%. At t2, patent fenestration (33%), veno-venous collaterals (24%) or both (32%) were present. Thirty-six (11%) patients died during follow-up. In a time-varying multivariable Cox regression analysis, cyanosis was the strongest predictor for late mortality (P < 0.001, hazard ratio 12.2, 95% confidence interval 3.7-40.5). CONCLUSIONS Prevalence of cyanosis was considerable during long-term follow-up after Fontan operation and-as a surrogate parameter for unfavourable Fontan haemodynamics-is associated with increased late mortality. Accordingly, particular attention should be directed towards the persistence or reoccurrence of cyanosis during follow-up since it may indicate haemodynamic attrition and development of Fontan failure.
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Affiliation(s)
- Marie Schafstedde
- Department of Congenital Heart Disease/Paediatric Cardiology, German Heart Center Berlin, Berlin, Germany.,Institute for Cardiovascular Computer-Assisted Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
| | - Sarah Nordmeyer
- Department of Congenital Heart Disease/Paediatric Cardiology, German Heart Center Berlin, Berlin, Germany.,Institute for Cardiovascular Computer-Assisted Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Anastasia Schleiger
- Department of Congenital Heart Disease/Paediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Johannes Nordmeyer
- Department of Congenital Heart Disease/Paediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Felix Berger
- Department of Congenital Heart Disease/Paediatric Cardiology, German Heart Center Berlin, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany.,Department of Paediatric Cardiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Kramer
- Department of Congenital Heart Disease/Paediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Paediatric Cardiology, German Heart Center Berlin, Berlin, Germany
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Oka N, Miyamoto T, Tomoyasu T, Hayashi H, Miyaji K. Risk Factors for Mid-Term Liver Disease After the Fontan Procedure. Int Heart J 2020; 61:979-983. [DOI: 10.1536/ihj.20-059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Norihiko Oka
- Department of Cardiovascular Surgery, Gunma Children's Medical Center
| | - Takashi Miyamoto
- Department of Cardiovascular Surgery, Kitasato University School of Medicine
| | - Takahiro Tomoyasu
- Department of Cardiovascular Surgery, Gunma Children's Medical Center
| | - Hidenori Hayashi
- Department of Cardiovascular Surgery, Gunma Children's Medical Center
| | - Kagami Miyaji
- Department of Cardiovascular Surgery, Kitasato University School of Medicine
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Predicting the pressure of the total cavopulmonary connection: clinical testing of a mathematical equation. Cardiol Young 2019; 29:1066-1071. [PMID: 31331409 DOI: 10.1017/s1047951119001513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Some authors advocate the use of a dedicated formula to predict the Fontan pressure starting from pre-Fontan catheterisation data. This paper aims at testing the predictive value of the mentioned formula through a retrospective clinical study. METHODS AND RESULTS Pre-Fontan catheterisation data and Fontan pressure measured at the completion were retrospectively collected. Pre-Fontan data were used to calculate the predicted pressure in the Fontan system. The predicted values were compared to the Fontan pressure measured at the Fontan completion and with the needs for fenestration. One hundred twenty-four Fontan patients were retrospectively enrolled (At Fontan: median age 30.73 [24.70-37.20] months, median weight 12.00 [10.98-14.15] kg). Fontan conduit was fenestrated in 78 patients. A poor correlation (r2 = 0.05128) between the measured and predicted data for non-fenestrated patients was observed. In the case of Fontan-predicted pressure <17.59 mmHg, the formula identified a good short-term clinical outcome with a sensitivity of 92%. CONCLUSION The proposed formula showed a poor capability in estimating the actual pressure into the Fontan system and in identifying patients needing fenestration. As the pressure into the Fontan system is determined by multiple factors, the tested formula could be an additional data in a multi-parametric approach.
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Abstract
BACKGROUND The benefits of fenestration for patients undergoing Fontan procedure seem controversial at early and late postoperative stages. OBJECTIVE We aimed to compare the outcomes between the fenestrated and non-fenestrated Fontan procedures. METHODS Studies comparing the fenestrated and non-fenestrated Fontan procedures were identified by searching the PubMed, EMBASE, and Cochrane Library databases until July 2018. The assessed variables included postoperative oxygen saturation (SaO2), pulmonary artery pressure, mortality, cardiopulmonary bypass (CPB) time, ventilation time, intensive care unit stay, hospital stay, chest tube duration, protein-losing enteropathy, arrhythmia, and other follow-up outcomes including reintervention, stroke/thrombosis, and peak oxygen consumption. A random-effect/fixed-effect model was used to summarize the estimates of the mean difference (MD)/odds ratio (OR) with 95% confidence interval (CI). Subgroup analysis stratified by early and late outcomes was performed. RESULTS A total of 1929 Fontan patients from 14 studies were included. The early postoperative SaO2 was lower with fenestration than without fenestration (MD -2.52, 95% CI -4.16 to -0.87, P <.05); however, the late postoperative SaO2 showed no difference between the 2 approaches. The CPB time was shorter without fenestration than with fenestration (MD 10.72, 95% CI 2.54-18.9, P <.05); however, the incidence of arrhythmia was lower with fenestration than without fenestration (OR 0.43, 95% CI 0.25-0.75, P <.05). Other variables showed no significant differences between the 2 approaches in Fontan patients. CONCLUSION Fenestration appears to result in a lower incidence of arrhythmia but with a longer CPB time and lower early SaO2. Other outcomes are comparable between the 2 approaches.
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Affiliation(s)
- Dongxu Li
- Department of Cardiovascular Surgery
| | - Mengsi Li
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan
| | - Xu Zhou
- Evidence-based Medicine Research Center, School of Basic Medical Sciences, Jiangxi University of Traditional Chinese Medicine, Jiangxi, China
| | - Qi An
- Department of Cardiovascular Surgery
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Hill GD, Ghanayem NS, Hraska V, Jacobsen RM, Mitchell ME, Woods RK, Ginde S. Variation in the use of Fontan fenestration in the current surgical era. PROGRESS IN PEDIATRIC CARDIOLOGY 2019. [DOI: 10.1016/j.ppedcard.2018.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Korun O, Çiçek M, Yurdakök O, Hekim Yılmaz E, Çelebi A, Yurtseven N, Şaşmazel A, Ali Aydemir N. A dramatic learning curve of extracardiac Fontan operation in the modern era. Asian Cardiovasc Thorac Ann 2019; 27:172-179. [PMID: 30789306 DOI: 10.1177/0218492319831832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND This study aimed to describe the learning curve of the extracardiac Fontan procedure in a single center and to analyze the changes in clinical applications and outcomes. METHODS A retrospective chart review of all extracardiac Fontan patients in a single tertiary care center was undertaken. Patients with a diagnosis of hypoplastic left heart syndrome and those who had undergone a lateral tunnel modification, intra/extracardiac Fontan, Kawashima procedure, or inferior vena cava-to-azygous vein connection were excluded from the analysis. RESULTS Between May 2004 and February 2018, data of 159 extracardiac Fontan patients were analyzed. The median age was 5.5 years (range 4.5-8.2 years). Based on a cumulative sum analysis, a hinge point was determined to divide the cohort into 2 phases. Phase 1 ( n = 70) represented the first learning phase and phase 2 ( n = 89) represented the later phase. Mortality decreased in phase 2 (2/89; 2%) compared to phase 1 (10/70; 14%; p = 0.004). Two (3%) patients had extracorporeal membrane oxygenation in phase 1, and 5 (6%) in phase 2 ( p = 0.47). More patients in phase 2 underwent a prior bidirectional Glenn procedure (83/89 vs. 57/70; p = 0.02), fenestration (80/89 vs. 9/70; p < 0.001), and pulmonary artery reconstruction (37/89 vs. 2/70; p < 001). CONCLUSIONS This study shows that increased use of extracorporeal membrane oxygenation, strict implementation of the three-stage management plan, routine fenestration, and a low threshold for pulmonary artery reconstruction may be associated with decreased mortality in the extracardiac Fontan procedure.
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Affiliation(s)
- Oktay Korun
- 1 Pediatric Cardiac Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Turkey
| | - Murat Çiçek
- 1 Pediatric Cardiac Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Turkey
| | - Okan Yurdakök
- 1 Pediatric Cardiac Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Turkey
| | - Emine Hekim Yılmaz
- 2 Pediatric Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Turkey
| | - Ahmet Çelebi
- 2 Pediatric Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Turkey
| | - Nurgül Yurtseven
- 3 Anesthesiology and Reanimation, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Turkey
| | - Ahmet Şaşmazel
- 1 Pediatric Cardiac Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Turkey
| | - Numan Ali Aydemir
- 1 Pediatric Cardiac Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Turkey
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Fan Q, Ling Y, Wang Y, An Q. Easy technique for emergency fenestration in non-fenestrated Fontan patients. Interact Cardiovasc Thorac Surg 2017; 25:1001-1002. [PMID: 29049712 DOI: 10.1093/icvts/ivx217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 05/30/2017] [Indexed: 02/05/2023] Open
Abstract
The Fontan procedure is a commonly used final pathway of palliation for single-ventricle physiology. Performing it without fenestration can avoid fenestration-related drawbacks, including subnormal oxygen saturation, decreased exercise tolerance, paradoxical embolization and subsequent need for closure by catheter intervention. If emergency fenestration is required, however, it is not always technically easy to perform, particularly when the atrium is posteriorly located and difficult to expose. We describe an easy technique for creating an anastomosis using a ring-supported polytetrafluoroethylene graft to the atrium for fenestration, performed in 2 patients who underwent extracardiac conduit Fontan procedures without fenestration.
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Affiliation(s)
- Qiang Fan
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Cheng Du, Sichuan, China
| | - Yunfei Ling
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Cheng Du, Sichuan, China
| | - Yabo Wang
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Cheng Du, Sichuan, China
| | - Qi An
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Cheng Du, Sichuan, China
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Talwar S, Singh S, Sreenivas V, Kapoor KS, Gupta SK, Ramakrishnan S, Kothari SS, Saxena A, Juneja R, Choudhary SK, Airan B. Outcomes of Patients Undergoing Primary Fontan Operation Beyond First Decade of Life. World J Pediatr Congenit Heart Surg 2017; 8:487-494. [PMID: 28696879 DOI: 10.1177/2150135117713696] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Studies on older patients undergoing primary Fontan operation (FO) are limited, with conflicting results. We review our experience with these patients beyond the first decade of life. PATIENTS AND METHODS Between January 2000 and December 2014, a total of 105 patients ≥10 years of age (mean 15.6 ± 4.9, range 10-31, median 15 years) underwent primary FO without a prior bidirectional superior cavopulmonary anastomosis (Bidirectional Glenn [BDG]). Mean preoperative New York Heart Association (NYHA) class was 2.2 ± 0.57. RESULTS Operative procedure was extra-cardiac FO in 62 patients (8 were fenestrated). Forty-three had a lateral tunnel FO (26 were fenestrated). There were 11 (10.5%) early deaths. Fourteen of the 94 early survivors experienced prolonged pleural effusions, 7 had arrhythmias, and 2 had thromboembolic events. Two patients underwent Fontan takedown. On univariate analysis, NYHA functional class III, mean pulmonary artery (PA) pressure ≥15 mm Hg, hematocrit ≥60%, preoperative ventricular dysfunction, and atrioventricular valve regurgitation (AVVR) were associated with early mortality. Median follow-up was 78 (mean 88.9 ± 6.3) months. In 94 survivors, 6 (6.4%) late deaths were encountered. At last follow-up, 81 (86.2%) survivors were in NYHA class I. Actuarial survival was 84.7% ± 3.7% at 5, 10, and 15 years. CONCLUSION Carefully selected adolescents and young adults can safely undergo the primary FO. However, persistent pleural effusions, arrhythmias, thromboembolic events, and the need for reoperation mandate regular follow-up in such patients. Preoperative NYHA functional class III, mean PA pressure ≧ 15 mm Hg, hematocrit ≥ 60%, ventricular dysfunction, and AVVR were associated with early mortality, suggesting that primary FO should be avoided in such patients.
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Affiliation(s)
- Sachin Talwar
- 1 Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sukhjeet Singh
- 1 Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Vishnubhatla Sreenivas
- 2 Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Kulwant Singh Kapoor
- 2 Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Kumar Gupta
- 3 Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Shyam Sunder Kothari
- 3 Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Anita Saxena
- 3 Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Rajnish Juneja
- 3 Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Shiv Kumar Choudhary
- 1 Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Balram Airan
- 1 Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
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Zou M, Wang Y, Cui H, Ma L, Yang S, Xia Y, Chen W, Chen X. Outcomes of total cavopulmonary connection for single ventricle palliation. J Thorac Dis 2016; 8:43-51. [PMID: 26904211 DOI: 10.3978/j.issn.2072-1439.2016.01.41] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND The aim of this study was to review the early and mid-term outcomes of the total cavopulmonary connection (TCPC) procedure and evaluate risk factors for prolonged pleural effusions. METHODS The clinical records of 82 consecutive patients, who underwent a TCPC operation between January 2008 and December 2013, were reviewed for incidence of prolonged pleural effusions, duration of ventilation time and pleural drainage, length of intensive care unit (ICU) stay, and early and mid-term morbidity and mortality. RESULTS The median age at surgery was 3.0 years. The main single ventricle diagnoses included 18 cases of a double-inlet single ventricle, 17 cases of heterotaxy, 16 cases of tricuspid atresia, 4 cases of mitral atresia, 12 cases of unbalanced complete atrioventricular canal (CAVC), 5 cases of double-outlet right ventricle (DORV) combined with ventricular septal defect (VSD) and pulmonary stenosis (PS), 4 cases of transposition of the great arteries (TGA) combined with VSD and PS, 4 cases of corrected transposition of great arteries (cTGA) combined VSD and PS, and 2 cases of criss-cross heart. Preoperative mean pulmonary artery pressure (mPAP) was 13.66±2.21 mmHg with 23.2% (n=19) higher than 15 mmHg. A total of 61 (74.4%) patients underwent a fenestration. The perioperative mortality was 4.9%. The median duration of pleural effusion was 10 days (range, 3-80 days), and prolonged pleural effusions occurred in 16 (19.5%) patients. Multivariable analysis revealed that mPAP >15 mmHg was independently associated with prolonged pleural effusions (OR, 8.33; 95% CI, 2.33-29.74; P=0.001), and creation of a fenestration was associated with decreased odds of effusion (OR, 0.21; 95% CI, 0.06-0.74; P=0.015). Five-year estimated Kaplan-Meier survival of two-stage TCPC was significantly higher than that of one-stage group(96.7% vs. 79.7%, P=0.023). Patients with heterotaxy or obstructed totally anomalous pulmonary venous connection (TAPVC) had significantly worse mid-term survival. CONCLUSIONS Staged TCPC improved the early and mid-term survival of patients with a single ventricle. mPAP >15 mmHg was independently associated with prolonged pleural effusions and a fenestration significantly associated with a lower odds of effusion.
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Affiliation(s)
- Minghui Zou
- Department of Cardiovascular Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou 510623, China
| | - Yanfei Wang
- Department of Cardiovascular Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou 510623, China
| | - Hujun Cui
- Department of Cardiovascular Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou 510623, China
| | - Li Ma
- Department of Cardiovascular Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou 510623, China
| | - Shengchun Yang
- Department of Cardiovascular Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou 510623, China
| | - Yuansheng Xia
- Department of Cardiovascular Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou 510623, China
| | - Weidan Chen
- Department of Cardiovascular Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou 510623, China
| | - Xinxin Chen
- Department of Cardiovascular Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou 510623, China
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De Wolf D, Dessy H, Haas N. Use of a new low profile Occlutech PLD device for closure of Fontan fenestrations. Catheter Cardiovasc Interv 2015; 87:E243-7. [PMID: 26526601 DOI: 10.1002/ccd.26271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 09/14/2015] [Accepted: 10/01/2015] [Indexed: 11/07/2022]
Abstract
For some higher risk patients, fenestrations are still created in total cavopulmonary connection conduits completing the Fontan circulation for univentricular hearts. If these fenestrations remain patent and hemodynamics are favorable, they are closed to improve oxygenation and exercise tolerance and to decrease the risk of paradoxical emboli. Depending on the type of fenestration, different devices are used. Unfortunately, the search for the ideal device is still ongoing. We propose the first experience with the off-label use of the new Occlutech paravalvular leak device. This device offers the combination of a small delivery sheath size, high flexibility, less material, and a low profile. The low profile in particular could be an advantage in order to reduce the risk of thrombus formation in the low velocity flow environment of the Fontan circulation. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Daniel De Wolf
- Department of Pediatric Cardiology, Ghent University Hospital, Gent, Belgium
| | - Hugues Dessy
- Department of Pediatric Cardiology, HUDERF, Brussels, Belgium
| | - Nikolaus Haas
- Department for Congenital Heart Defects, Heart and Diabetes Centre North Rhine Westphalia, Ruhr University Bochum, Germany
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Abstract
Although mortality is low after the modified Fontan procedure, there is a significant percentage of patients with prolonged postoperative recovery. The objective of this study is to evaluate the usefulness of postoperative administration of oral sildenafil and inhaled nitric oxide on early postoperative outcome. A prospective interventional and comparison study with a historical cohort was conducted. Between January, 2010 and March, 2013, 16 patients received oral sildenafil during immediate modified Fontan postoperative period. Inhaled nitric oxide was also administered if the patient was kept intubated 12 hours after surgery. Early postoperative outcome was compared with a historical cohort of 32 patients on whom the modified Fontan procedure was performed between March, 2000 and December, 2009. Postoperative administration of sildenafil and nitric oxide had no influence on early postoperative outcome after the modified Fontan procedure in terms of duration of pleural effusions, mechanical ventilation time, length of stay in the ICU, and length of hospital stay.
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Davies RR, Pizarro C. Decision-Making for Surgery in the Management of Patients with Univentricular Heart. Front Pediatr 2015; 3:61. [PMID: 26284226 PMCID: PMC4515559 DOI: 10.3389/fped.2015.00061] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 06/21/2015] [Indexed: 12/24/2022] Open
Abstract
A series of technical refinements over the past 30 years, in combination with advances in perioperative management, have resulted in dramatic improvements in the survival of patients with univentricular heart. While the goal of single-ventricle palliation remains unchanged - normalization of the pressure and volume loads on the systemic ventricle, the strategies to achieve that goal have become more diverse. Optimal palliation relies on a thorough understanding of the changing physiology over the first years of life and the risks and consequences of each palliative strategy. This review describes how to optimize surgical decision-making in univentricular patients based on a current understanding of anatomy, physiology, and surgical palliation.
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Affiliation(s)
- Ryan Robert Davies
- Nemours Cardiac Center, A. I. duPont Hospital for Children , Wilmington, DE , USA ; Thomas Jefferson University , Philadelphia, PA , USA
| | - Christian Pizarro
- Nemours Cardiac Center, A. I. duPont Hospital for Children , Wilmington, DE , USA ; Thomas Jefferson University , Philadelphia, PA , USA
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Umezu K, Harada Y, Sakamoto T, Maekawa Y, Takigiku K, Yasukochi S. Fontan completion after Norwood with bidirectional Glenn shunt: their haemodynamics and pulmonary artery configuration. Interact Cardiovasc Thorac Surg 2012; 15:204-8. [PMID: 22572411 DOI: 10.1093/icvts/ivs138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES We ranked the haemodynamics and pulmonary artery (PA) configurations of Norwood with bidirectional Glenn shunt (NW-G) patients among the other staged Fontan completion (conventional) patients in this study. METHODS Between August 2001 and April 2010, 91 consecutive patients completed staged Fontan operations. Among them, NW-G was performed in 11. RESULTS There was no operative or late death except in one case which resulted from a reoperation after Fontan completion. Although the age at bidirectional Glenn (BDG) and Fontan completion was younger in NW-G (4.2 vs. 10.9 months, P < 0.01, and 2.3 vs. 3.3 years, P < 0.01), the interval between BDG and Fontan completion was not significantly different in these groups (23.6 vs. 28.0 months, P = 0.71). On Fontan completion, the extracardiac conduit size was significantly different (16.4 vs. 17.7 mm, P < 0.01). However, the pulmonary artery size (PA index) and the PA pressure were not significantly different (165.4 vs. 205.1 mm(2)/m(2), P = 0.23, and 13.4 vs. 11.0 mmHg, P = 0.08). Particularly in hypoplastic left heart syndrome patients, the PA index was not significantly different between these groups (165.4 vs. 174.9 mm(2)/m(2), P = 0.59). CONCLUSIONS The NW-G patients could have a subsequent Fontan completion with good results. There was no significant difference with respect to Fontan completion.
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Affiliation(s)
- Kentaro Umezu
- Division of Cardiovascular Surgery, Nagano Children's Hospital, Nagano, Japan.
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Mendoza A, Albert L, Ruiz E, Boni L, Ramos V, Velasco JM, Herrera D, Granados MA, Comas JV, Perez A. Operación de Fontan. Estudio de los factores hemodinámicos asociados a la evolución postoperatoria. Rev Esp Cardiol 2012; 65:356-62. [DOI: 10.1016/j.recesp.2011.11.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 11/22/2011] [Indexed: 10/14/2022]
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Feinstein JA, Benson DW, Dubin AM, Cohen MS, Maxey DM, Mahle WT, Pahl E, Villafañe J, Bhatt AB, Peng LF, Johnson BA, Marsden AL, Daniels CJ, Rudd NA, Caldarone CA, Mussatto KA, Morales DL, Ivy DD, Gaynor JW, Tweddell JS, Deal BJ, Furck AK, Rosenthal GL, Ohye RG, Ghanayem NS, Cheatham JP, Tworetzky W, Martin GR. Hypoplastic left heart syndrome: current considerations and expectations. J Am Coll Cardiol 2012; 59:S1-42. [PMID: 22192720 PMCID: PMC6110391 DOI: 10.1016/j.jacc.2011.09.022] [Citation(s) in RCA: 349] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Revised: 09/06/2011] [Accepted: 09/20/2011] [Indexed: 01/25/2023]
Abstract
In the recent era, no congenital heart defect has undergone a more dramatic change in diagnostic approach, management, and outcomes than hypoplastic left heart syndrome (HLHS). During this time, survival to the age of 5 years (including Fontan) has ranged from 50% to 69%, but current expectations are that 70% of newborns born today with HLHS may reach adulthood. Although the 3-stage treatment approach to HLHS is now well founded, there is significant variation among centers. In this white paper, we present the current state of the art in our understanding and treatment of HLHS during the stages of care: 1) pre-Stage I: fetal and neonatal assessment and management; 2) Stage I: perioperative care, interstage monitoring, and management strategies; 3) Stage II: surgeries; 4) Stage III: Fontan surgery; and 5) long-term follow-up. Issues surrounding the genetics of HLHS, developmental outcomes, and quality of life are addressed in addition to the many other considerations for caring for this group of complex patients.
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Affiliation(s)
- Jeffrey A Feinstein
- Department of Pediatrics, Stanford University School of Medicine, Lucile Salter Packard Children's Hospital, Palo Alto, California 94304, USA.
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16
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Sakamoto T, Harada Y, Kosaka Y, Umezu K, Yasukochi S, Takigiku K, Matsui H, Inoue N. Second-Stage Palliation After Bilateral Pulmonary Artery Bands for HLHS and its Variants—Which is Better, Modified Norwood or Norwood Plus Bidirectional Glenn? World J Pediatr Congenit Heart Surg 2011; 2:558-65. [DOI: 10.1177/2150135111415428] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. The purpose of this study was to evaluate the surgical outcomes and pulmonary artery (PA) development associated with a new strategy wherein the modified Norwood (N) procedure is performed at 1-2 months after bilateral pulmonary artery banding (PAB). Methods. Between January 2008 and February 2010, 16 patients underwent Norwood-type operation after previous bilateral PAB. For analysis, patients were divided into two groups. Group I (n = 11) underwent modified Norwood procedure with either right modified Blalock Taussig (RMBT) shunt (n = 4) or right ventricle to pulmonary artery (RV-PA) conduit (n = 7). Group II (n = 5) underwent Norwood procedure plus bidirectional Glenn anastomosis. Diagnoses were hypoplastic left heart syndrome in 6 and its variants in 10. Results. There was no surgical death and no late death. Pulmonary artery interventions were performed at the time of the Norwood procedure in 27% in Group I and in 100% in Group II (p < 0.05). Additional PA interventions were performed during the period of follow-up in 4 cases in Group I (36.4%), and in 4 cases in Group II (80.0%). Additional Blalock Taussig shunts were performed in 7 patients, resulting in significant increase in PA index. In all, four patients have reached total cavopulmonary connection, and one has undergone biventricular repair. Eight patients in Group I and one patient in II Group reached bidirectional Glenn anastomosis. In Gp II, two patients showed LPA narrowing or obstruction with PA index of 80 ± 12 mm2/m2. Conclusions. Regarding the second-stage palliation after bilateral PAB, modified Norwood procedure with either RMBT or RV-PA conduit has some advantages compared with Norwood plus BDG with respect to subsequent pulmonary artery development. Additional BT shunt may contribute to PA development, even in the patients with Norwood procedure with RV-PA conduit.
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Affiliation(s)
- Takahiko Sakamoto
- Department of Cardiovascular Surgery, Nagano Children’s Hospital, Azumino-City, Nagano, Japan
| | - Yorikazu Harada
- Department of Cardiovascular Surgery, Nagano Children’s Hospital, Azumino-City, Nagano, Japan
| | - Yoshimichi Kosaka
- Department of Cardiovascular Surgery, Nagano Children’s Hospital, Azumino-City, Nagano, Japan
| | - Kentaro Umezu
- Department of Cardiovascular Surgery, Nagano Children’s Hospital, Azumino-City, Nagano, Japan
| | - Satoshi Yasukochi
- Department of Pediatric Cardiology, Nagano Children’s Hospital, Azumino-City, Nagano, Japan
| | - Kiyohiro Takigiku
- Department of Pediatric Cardiology, Nagano Children’s Hospital, Azumino-City, Nagano, Japan
| | - Hikoro Matsui
- Department of Pediatric Cardiology, Nagano Children’s Hospital, Azumino-City, Nagano, Japan
| | - Nao Inoue
- Department of Pediatric Cardiology, Nagano Children’s Hospital, Azumino-City, Nagano, Japan
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Backer CL, Deal BJ, Kaushal S, Russell HM, Tsao S, Mavroudis C. Extracardiac versus intra-atrial lateral tunnel fontan: extracardiac is better. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2011; 14:4-10. [PMID: 21444042 DOI: 10.1053/j.pcsu.2011.01.019] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
This article was prepared to summarize the points made in a debate that the first author (C.L.B.) had with Dr. Richard Jonas at the American Association for Thoracic Surgery 90th Annual Meeting. The topic of the debate was the optimal surgical approach for functional single-ventricle patients: extracardiac versus intra-atrial lateral tunnel Fontan. My role was to take the viewpoint that the extracardiac Fontan is better. This review summarizes our results at Children's Memorial Hospital (Chicago, IL) with 180 patients undergoing a primary Fontan procedure and 126 patients undergoing an extracardiac Fontan as part of a Fontan conversion. The world literature was reviewed on outcomes following the Fontan procedure, focusing on six main areas supporting the superiority of the extracardiac Fontan: hemodynamics, arrhythmias, applicability to complex anatomy, use of cardiopulmonary bypass, complications of fenestration and thromboembolism, and operative mortality. Based on this review, it is our conclusion that the extracardiac Fontan is the procedure of choice for patients with a functional single ventricle based on a very low operative mortality, a lower incidence of early and late arrhythmias, improved hemodynamics, fewer postoperative complications, and applicability to a wide variety of complex cardiac anatomy.
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Affiliation(s)
- Carl Lewis Backer
- Division of Cardiovascular-Thoracic Surgery, Children's Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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18
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Salazar JD, Zafar F, Siddiqui K, Coleman RD, Morales DLS, Heinle JS, Rossano JW, Mossad EB, Fraser CD. Fenestration during Fontan palliation: now the exception instead of the rule. J Thorac Cardiovasc Surg 2010; 140:129-36. [PMID: 20620378 DOI: 10.1016/j.jtcvs.2010.03.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2009] [Revised: 02/21/2010] [Accepted: 03/16/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Fenestration during Fontan palliation has traditionally been used to decrease surgical morbidity and mortality, particularly in high-risk cases. Potential limitations include oxygen desaturation, risk of paradoxic embolism, and need for late intervention. Our practice has evolved away from routine fenestration with increased extracardiac conduit use. We reviewed our experience with Fontan palliation and retrospectively assessed outcomes with decreased fenestration. METHODS Between January 2002 and April 2008, 226 patients underwent primary Fontan palliation. Outcomes were assessed by hospital stay, chest drain duration, short- and long-term survivals, and late interventions. RESULTS Anatomic subtypes were single left ventricle (n = 88, 38.9%), single right ventricle (n = 78, 34.5%), common ventricle (n = 19, 8.4%), and heterotaxy syndrome (n = 41, 18.1%). Lateral tunnel connection was created in 69 patients (30.5%); extracardiac connection was created in 157 (69.5%). Mean age and weight at surgery were 4.3 +/- 3.8 years and 17.2 +/- 9 kg, respectively. In 2002, 14 of 16 patients (87.5%) had fenestrated Fontan circulations, versus 2 of 32 (6.3%) in 2008. Mean hospital stay was 10.8 +/- 8.8 days. Survival to discharge or 30 days was 98.7%. There were 2 (0.9%) late deaths during mean follow-up of 2.0 +/- 1.7 years. Outcomes were equivalent between fenestrated and nonfenestrated procedures across anatomic subtypes. CONCLUSIONS Highly selective use of Fontan fenestration is achievable while maintaining excellent outcomes without increased surgical morbidity or mortality, irrespective of anatomic subtype. Risks of hypoxia, systemic embolism, and late instrumentation can be avoided in most cases.
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Affiliation(s)
- Jorge D Salazar
- Division of Congenital Heart Surgery, Baylor College of Medicine, Houston, Tex, USA.
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Nakata T, Fujimoto Y, Hirose K, Osaki M, Tosaka Y, Ide Y, Tachi M, Sakamoto K. Fontan completion in patients with atrial isomerism and separate hepatic venous drainage. Eur J Cardiothorac Surg 2010; 37:1264-70. [PMID: 20138532 DOI: 10.1016/j.ejcts.2009.12.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2009] [Revised: 12/16/2009] [Accepted: 12/21/2009] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Fontan completion in patients with atrial isomerism, in which the inferior vena cava (IVC) and the hepatic vein (HV) drain separately, is technically challenging. Herein, we review our surgical approach to these patients. METHODS The medical records of 50 consecutive patients with atrial isomerism who underwent Fontan completion between 1998 and 2008 were reviewed retrospectively. RESULTS Separate HV drainage was present in 17 patients. Patients with interrupted IVC were excluded. Patient characteristics were as follows: median age, 26 months (range 15-149); median weight, 9.6 kg (range 8.1-47.2); right atrial isomerism, 16 patients; and left atrial isomerism, one. The IVC and the separate HV at the level of diaphragm were contralateral in 16 patients, and ipsilateral in one. The surgical procedures for directing blood flow from the IVC and the separate HV to the pulmonary arteries were as follows: en bloc resection of the IVC and the HV and anastomosing these veins to an extracardiac conduit in 10 patients; connecting the IVC to the HV in a side-to-side fashion before anastomosing them to an extracardiac conduit in one; and lateral tunnel in another. When the IVC and the HV were widely separated by the vertebrae, we chose an intra-extracardiac conduit (intra-atrial septation) in four patients and an extracardiac conduit for the IVC and the right HV and lateral tunnel for the separate left HV in one. There was no mortality. Five re-operations were performed (pacemaker in two patients; one each of fenestration, release of outflow obstruction and ligation of collateral arteries). Sixteen patients underwent follow-up catheterisation, which revealed central venous pressure of 12.0 + or - 2.0 mmHg and arterial oxygen saturation of 92% + or - 6%. CONCLUSIONS The mid-term results of the Fontan completion in patients with atrial isomerism and separate HV drainage were excellent. The distance between the IVC and the separate HV and the position of the vertebrae should be considered when choosing a surgical technique.
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Affiliation(s)
- Tomohiro Nakata
- Department of Cardiovascular Surgery, Kyoto University, Graduate School of Medicine, Kyoto, Japan
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