Modified Fontan operation in patients with anomalies of systemic and pulmonary venous connection

Impact of Era, Type of Isomerism, and Ventricular Morphology on Survival in Heterotaxy: Implications for Therapeutic Management

BACKGROUND

Heterotaxy has been demonstrated to reduce survival. There are several different subgroups of patients, however, and no single study has had a large number of patients and analyzed survival across the different subgroups such as patients born in different eras, patients with right and left isomerism, and patients with biventricular or functionally univentricular hearts. This study pools previously reported data from Kaplan-Meier curves and performs such subgroup analysis.

METHODS

A systematic review of the literature was performed to identify studies reporting survival of patients with the so-called "heterotaxy" by means of Kaplan-Meier survival curves. Data were extracted from these survival curves and then pooled together. A polynomial regression was then used to generate a pooled survival curve. This was done for all patients, those born in a more recent era, those with right and left isomerism, and those with biventricular or functionally univentricular hearts.

RESULTS

Those born in the more recent era (after 2000) had increased survival compared to the overall cohort. Those with left isomerism tended to have a survival benefit compared to those with right isomerism until about 16 years of age, beyond which those with right isomerism developed a survival benefit. Those with biventricular hearts had a survival benefit compared to those with left isomerism.

CONCLUSION

Survival in the so-called heterotaxy syndrome is based on several factors, which include era of birth, sidedness of isomerism, and whether the heart is biventricular or functionally univentricular.

Management of partial anomalous pulmonary venous connection in single ventricle

We herein report a case of a hypoplastic left heart syndrome variant complicated with partial anomalous pulmonary venous connection to the left innominate vein. We left the vertical vein at the time of the bidirectional Glenn procedure, and ligated the vertical vein at the time of the total cavopulmonary connection procedure, without reconnecting the vertical vein to the left atrium. Because of the development of an interlobar vein draining from the left upper lung into the lower lung after the bidirectional Glenn procedure, the circulation of the left upper lung was preserved after the total cavopulmonary connection procedure.

Fontan completion in patients with atrial isomerism and separate hepatic venous drainage

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.

Rational approach to surgical management of complex forms of double outlet right ventricle with modified Fontan operation

OBJECTIVE

Surgical alternatives to biventricular repair of complex forms of double outlet right ventricle (DORV) remain controversial. The available knowledge of the Fontan operation (FO) for children with this anomaly is limited. The aim of this report is to analyze the results and risk factors of the FO performed as an alternative to the biventricular repair of complex DORV.

METHODS

Between 1980 and 2007, 47 patients with complex forms of DORV underwent a modified FO. Concomitant defects included noncommitted, subpulmonary or multiple ventricular septal defects, anomalies of atrioventricular valves and/or caval veins, and ventricular hypoplasia. Thirty-five of 45 patients (77%) have undergone a hemi-Fontan and 35 patients (77%; 10 children without previous hemi-Fontan) have had a completion FO without mortality or Fontan takedown. Risk factors for adverse outcomes were determined by multivariate analyses.

RESULTS

There were no early but six late deaths. The follow-up period ranged from 1 year to 25 years (mean 10.0 +/- 6.5). The actuarial survival was 93% at 1 year, 87% at 10, 15, and 25 years. Multivariate analysis identified preoperative left or common atrioventricular valve insufficiency (P = .001) and decreased left ventricular ejection fraction (<50%) (P = .02) as risk factors for late death and/or morbidity. The only risk factor for a late adverse outcome and poor functional status was increased preoperative pulmonary vascular resistance (>4.0 Woods units/m(2)) (P = .005).

CONCLUSION

FO provides good early- and mid-term results in the treatment of complex forms of DORV. The increased preoperative pulmonary vascular resistance was a significant negative risk factor for adverse outcome in this patient population.