Comparison of fenestrated and nonfenestrated patients undergoing extracardiac Fontan

Impact of Optimal Fenestration Size on Outcomes of High-Risk Fontan Patients

BACKGROUND

We aimed to analyze mid-term outcomes of the fenestrated Fontan procedure, focusing on the fenestration size.

METHODS

We retrospectively reviewed the outcomes of the fenestrated Fontan procedure. Among 165 patients who underwent the Fontan procedure from 2011 to 2021, fenestration was created in 27 patients with the highest risks, including those with hypoplastic left heart syndrome, hypoplastic pulmonary arteries, heterotaxy syndrome with high pulmonary vascular resistance, and pulmonary arterial pressure >15 mm Hg. The patients underwent the procedure at a median age of three years (body weight, 11.4 kg; body surface area, 0.54 m2). Fenestration sizes were 3.5 to 5 mm.

RESULTS

Spontaneous fenestration closure occurred within one year postoperatively in nine patients. Among them, three experienced Fontan failure, necessitating refenestration. Although fenestration size did not differ, the size corrected by body surface area at the time of surgery was smaller in patients with fenestration closure (6.4 mm/m2 vs 8.3 mm/m2, P < .05). Patients with a fenestration <7 mm/m2 were more likely to have fenestration closure within one year postoperatively, and those with a fenestration >9 mm/m2 were more likely to have severe desaturation and require home oxygen therapy following discharge.

CONCLUSIONS

Spontaneous fenestration closure affected the frequency of Fontan complications. A very small fenestration size corrected by body surface area was a significant risk factor for spontaneous closure. Conversely, a very large fenestration size corrected by body surface area resulted in severe desaturation. The optimal fenestration size to prevent early spontaneous closure and severe desaturation is approximately 8 mm/m2.

Improved Technique for Interventional Extracardiac Fontan

We have previously reported a simple technique for preparatory staging and subsequent interventional completion of an extracardiac Fontan procedure that anatomically and hemodynamically closely mimics a standard extracardiac Fontan. We describe herein modifications that simplify the original procedural sequence and that may allow wider application. Percutaneous completion can be achieved even without a radiofrequency probe, using electrocautery. Fenestration is also easy to perform if there is a clinical indication.

Does routine fenestration improve early and late postoperative outcomes in patients undergoing Fontan palliation?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: 'In [patients undergoing Fontan palliation] does [fenestration] affect [early and late postoperative outcomes]?' Altogether 509 papers were found using the reported search, of which 11 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Current data suggest that the use of fenestration has advantages in the immediate postoperative course, with fewer complications such as pleural effusions, shorter hospitalization and decreased early Fontan failure, but comparable long-term outcomes to a non-fenestrated approach. Fenestration should be used in high-risk patients or based on the haemodynamic parameters measured before weaning from cardiopulmonary bypass. Routine use may potentially lead to additional late fenestration closure procedures in some patients, without improving long-term outcomes.

Pleural Effusions After Congenital Cardiac Surgery Requiring Readmission: A Systematic Review and Meta-analysis

Patients with congenital heart disease (CHD) are surviving longer thanks to improved surgical techniques and increasing knowledge of natural history. Pleural effusions continue to be a complication that affect many surgical patients and are associated with increased morbidity, many times requiring readmission and additional invasive procedures. The risks for development of pleural effusion after hospital discharge are ill-defined, which leads to uncertainty related to strategies for prevention. Our primary objective was to determine, in patients with CHD requiring cardiopulmonary bypass, the prevalence of post-surgical pleural effusions leading to readmission. The secondary objective was to identify risk factors associated with post-surgical pleural effusions requiring readmission. We identified 4417 citations; 10 full-text articles were included in the final review. Of the included studies, eight focused on single-ventricle palliation, one looked at Tetralogy of Fallot patients, and another on pleural effusion in the setting of post-pericardiotomy syndrome. Using a random-effect model, the overall prevalence of pleural effusion requiring readmission was 10.2% (95% CI 4.6; 17.6). Heterogeneity was high (I² = 91%). In a subpopulation of patients after single-ventricle palliation, the prevalence was 13.0% (95% CI 6.0;21.0), whereas it was 3.0% (95% CI 0.4;6.75) in patients mostly with biventricular physiology. We were unable to accurately assess risk factors. A better understanding of this complication with a focus on single-ventricle physiology will allow for improved risk stratification, family counseling, and earlier recognition of pleural effusion in this patient population.

Comparison of pleural effusion between fenestrated and nonfenestrated extracardiac Fontan: A prospective randomized study

BACKGROUND

Fenestration of the baffle/conduit is believed to reduce pleural effusion following the Fontan operation. However, equivocal results have been observed with or without fenestration. This study aims to evaluate the efficacy of fenestration on the amount and duration of pleural effusion following the Fontan operation.

METHODS

About 40 patients undergoing extracardiac Fontan (ECF) were randomized into two groups: one with fenestration (ECF-F; n = 20) or without fenestration (ECF-NF; n = 20). Primary outcome was the amount and duration of pleural effusions. Secondary outcomes were time to removal of the chest tubes, hospital stay, and readmission to the hospital because of recurrent pleural within 30 days of the operation.

RESULTS

Mean age was 11.5 ± 5.07 (range, 8.7-13.5) years in the ECF-F group and 13.6 ± 0.4 years (range, 10.5-15.5) in the (ECF-NF) group. The total drain output was 7.89 mL/kg/d in ECF-NF compared with 6.9 mL/kg/d in the ECF-group (P = .14). Time for removal of pleural tubes was 14.6 ± 0.95 days in the ECF-NF group compared with 11.6 ± days in the ECF-F group. Total duration of hospital stay was higher but not significant in the ECF-NF group compared with the ECF-F group. Two patients in ECF-NF required readmission to the hospital within 30 days following discharge, while there were no readmissions in the ECF-F group.

CONCLUSION

Contrary to the literature, the creation of a fenestration in the ECF circuit was not clearly associated with a reduction in the amount and duration of pleural effusion compared with a non-fenestrated Fontan. These findings may be debatable in high risks versus low risk candidates. However in the present study, in a low risk canditates undergoing the Fontan operation, the daily amount of pleural drainage was no different. Larger studies are needed to confirm these findings.

Extracardiac Fontan Fenestration Device Closure with Amplatzer Vascular Plug II and Septal Occluder: Procedure Results and Medium-Term Follow-Up

The objective of this study was to determine medium-term morbidity and mortality of patients who have undergone device closure of an extracardiac Fontan fenestration with an Amplatzer Vascular Plug II (AVPII) or Septal Occluder (ASO). A secondary objective was to compare medium-term morbidity and mortality between these patients and other fenestrated Fontan patients. A retrospective chart review was performed on patients who underwent an extracardiac fenestrated Fontan procedure between 1992 and 2015 at Cardinal Glennon Children's Medical Center. Procedural and follow-up data were obtained and compared between those who underwent fenestration closure and those who did not. Additional outcome measures included whether the fenestration had spontaneously closed, morbidity and mortality, oxygen saturations, and hemodynamics pre- and post-closure. Fifty-nine of 118 patients (50%) with a fenestrated Fontan underwent 60 device closures of the fenestration. Thirty-two (53%) of these were with the AVPII and 28 (47%) with the ASO. There was one device embolization. At a median follow-up of 3.9 years, five patients suffered morbidity, including 2 with arrhythmias, 1 with plastic bronchitis, 1 with protein losing enteropathy, and 1 with stroke. There were no cardiopulmonary deaths in this group. Twenty-three of 118 patients (19%) had spontaneous closure. There was no difference in morbidity and mortality between patients who underwent percutaneous fenestration closure and those who either had spontaneous closure or a persistently patent fenestration. Device closure of Fontan fenestrations is a safe and effective procedure with minimal morbidity and mortality comparable to other patients with fenestrations.

Where are we after 50 years of the Fontan operation?

First introduced in 1971, the Fontan procedure is the final common destination for all patients with a functional single ventricle. The procedure itself has evolved tremendously over the last five decades. This review traces this journey and presents the importance, outcomes and future outlook of the procedure in the current era.

Prophylactic Opening of the Pleural Cavity for Postoperative Drainage is a Risk Factor for Prolonged Pleural Effusion After a Fontan Operation

Postoperative prolonged pleural effusion (PPE) remains a confounding problem after a Fontan operation. We aimed to describe the risk factors for PPE after a Fontan operation and to clarify the impact of prophylactic opening of the pleural cavity (POPC) for drainage tube insertion on PPE. We retrospectively reviewed the medical charts of 50 consecutive patients who underwent a Fontan operation at our institution. POPC for postoperative drainage was performed based on each surgeon's preference. Patients were divided into three groups for analysis: group A (n = 12), no opening; group B (n = 14), unilateral opening; and group C (n = 24), bilateral opening. At the time of surgery, the median age of our patient group was 26 months, with a median body weight of 10.5 kg. The volume of pleural effusion tended to be lower in group A than in groups B and C (p = 0.08). The median duration of drainage was significantly shorter (p = 0.03) in group A (3 days) than in group B (4 days) or C (5 days). Overall, 12 patients required chest tube drainage for ≥ 7 days. Multivariate analysis revealed POPC (p = 0.01) and postoperative water balance (p = 0.03) as independent predictors of PPE. POPC and postoperative water balance are risk factors for PPE after a Fontan operation. Therefore, avoiding POPC for postoperative drainage may reduce the risk of postoperative pleural effusion and morbidities associated with PPE after a Fontan operation.

Comparison of the fenestrated and non-fenestrated Fontan procedures: A meta-analysis

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.

The Superior Cavopulmonary Connection: History and Current Perspectives

The development of the superior cavopulmonary connection is a rich illustration of international influences in congenital cardiac surgery. The bidirectional Glenn and hemi-Fontan procedures have improved survival as both definitive and staged functional single ventricle palliation. The optimal timing of the second-stage superior cavopulmonary procedures varies by center but for low- and intermediate-risk patients, this may be within three to six months after the Norwood procedure. The list of risk factors continues to grow but the most frequently cited factors include atrioventricular valve regurgitation, decreased ventricular function, need for reintervention, and failure to attain nutritional and growth goals. Ongoing prospective, multi-institutional studies, particularly those fostered internationally by the World Society for Pediatric and Congenital Heart Surgery and other associations, will hopefully provide further clarification of the complex management issues related to patients with functional single ventricle physiology.

Long-Term Effects of Percutaneous Fenestration Following the Fontan Procedure in Adult Patients with Congenital Univentricular Heart

Background

The Fontan procedure, performed for univentricular heart, may also include the technique of percutaneous fenestration to create a small atrial septal defect (ASD) and a right-to-left shunt. The aim of this study was to evaluate the long-term effects of fenestration in adult patients who had a Fontan procedure for univentricular heart.

Material/Methods

Fontan surgery was performed in 39 patients, including 19 (49%) patients with fenestration (Group I), and 20 (51%) patients without the fenestration procedure (Group II). Laboratory tests in both groups included echocardiography, plethysmography, cardiopulmonary exercise testing, and 24-hour Holter monitoring.

Results

Compared with patients in Group I, patients in Group II had a significantly increased level of N-terminal pro-brain natriuretic peptide (NT-proBNP) (p=0.04), alkaline phosphatase (ALP) (p=0.01) and a significant increase in frequency of atrial fibrillation (p=0.04). Patients in Group I had a significantly increased systemic ventricular ejection fraction (SVEF) (p=0.05) and increased heart rate (HR) (p=0.006), heart rate reserve (HRR) (p=0.02), ventilatory equivalent (VE) (p=0.01), and VO₂ peak (p=0.05) on cardiopulmonary exercise testing (CPET). Renal, hematologic, and ventilatory parameters, and incidence of thromboembolism showed no significant differences between the groups.

Conclusions

Long-term follow-up of patients who underwent Fontan procedures with percutaneous fenestration had improved single ventricular function, lower NT-proBNP levels, improved exercise capacity, and reduced ALP levels. These findings indicate that percutaneous fenestration closure should be considered for adult patients who have undergone Fontan procedure for univentricular heart.

Utility of preoperative Holter monitoring in children undergoing extracardiac conduit Fontan operation

BACKGROUND

In patients undergoing extracardiac conduit Fontan (ECF) who require postoperative pacing, epicardial leads are usually required because of anatomical constraints. If indicated, these could be conveniently placed at the time of ECF. We have routinely performed ambulatory 24-hour Holter monitoring before ECF to determine the presence or absence of preoperative sinus node dysfunction, in an attempt to avoid repeat sternotomy at a later time.

METHODS

We performed a retrospective study of all patients undergoing ECF from January 2000 to December 2015.

RESULTS

Two hundred sixteen patients met inclusion criteria. Patients were separated into two groups, those with preoperative Holter monitoring (PHM, n = 150) and those without (No-PHM, n = 66). Ten patients (4.6%) underwent permanent pacemaker implantation at the time of ECF (eight patients [5.3%] in PHM vs two patients [3.0%] in No-PHM, P = 0.46). There were seven (3.2%) patients who underwent pacemaker implantation after ECF requiring repeat sternotomy (four patients [2.7%] in PHM vs three patients [4.5%] in No-PHM, P = 0.47). Fourteen (6.5%) patients underwent permanent epicardial lead placement without a pulse generator at the time of ECF. None from this group underwent pacemaker implantation to date (median follow-up of 5.7 years). The overall incidence of pacemaker implantation was 9.3% (20 patients).

CONCLUSIONS

In our series, arrhythmia disturbances requiring pacing after ECF occurred in just over 9% of patients. While PHM in those patients may help predict which patients might require postoperative pacing, this approach did not result in a significant decrease in those patients requiring repeat sternotomy for pacemaker implantation.

Impact of the location of the fenestration on Fontan circulation haemodynamics: a three-dimensional, computational model study

OBJECTIVES

There is no consensus or theoretical explanation regarding the optimal location for the fenestration during the Fontan operation. We investigated the impact of the location of the fenestration on Fontan haemodynamics using a three-dimensional Fontan model in various physiological conditions.

METHODS

A three-dimensional Fontan model was constructed on the basis of CT images, and a 4-mm-diameter fenestration was located between the extracardiac Fontan conduit and the right atrium at three positions: superior, middle, and inferior part of the conduit. Haemodynamics in the Fontan route were analysed using a three-dimensional computational fluid dynamic model in realistic physiological conditions, which were predicted using a lumped parameter model of the cardiovascular system. The respiratory effect of the caval flow was taken into account. The flow rate through the fenestration, the effect of lowering the central venous pressure, and wall shear stress in the Fontan circuit were evaluated under central venous pressures of 10, 15, and 20 mmHg. The pulse power index and pulsatile energy loss index were calculated as energy loss indices.

RESULTS

Under all central venous pressures, the middle-part fenestration demonstrated the most significant effect on enhancing the flow rate through the fenestration while lowering the central venous pressure. The middle-part fenestration produced the highest time-averaged wall shear stress, pressure pulse index, and pulsatile energy loss index.

CONCLUSIONS

Despite slightly elevated energy loss, the middle-part fenestration most significantly increased cardiac output and lowered central venous pressure under respiration in the Fontan circulation.

Fontan Operation: Indications, Short and Long Term Outcomes

Fontan operation, since its original description, has undergone a number of modifications so that it is now a staged, total cavo-pulmonary connection with fenestration. Stage I is palliation, depending upon the pathophysiology of the defect complex in early life, Stage II is bidirectional Glenn at about the age of 6 mo and Stage III is transfer of inferior vena caval blood to the pulmonary circuit along with fenestration between 2 to 4 y. Any patient that has only one functioning ventricle is a candidate for Fontan surgery. The morbidity and mortality have remarkably improved since the institution of staged, total cavo-pulmonary connection with fenestration. Complications during follow up continue to occur, though diminished with the newer modifications, and should be promptly addressed.

Decision-Making for Surgery in the Management of Patients with Univentricular Heart

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.