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Şimşek B, Özyüksel A, Demiroluk Ş, Saygı M, Bilal MS. Early outcomes of fenestrated intra-extracardiac Fontan procedure: Insights, experiences, and expectations. J Card Surg 2022; 37:1301-1308. [PMID: 35226377 DOI: 10.1111/jocs.16366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 01/04/2022] [Accepted: 01/18/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Intraextracardiac Fontan procedure (FP) aimed to combine the advantages of lateral tunnel and extracardiac conduit modifications of the original technique. Herein, we present our early outcomes in patients with intraextracardiac fenestrated FP. METHODS A retrospective analysis was performed to evaluate intraextracardiac fenestrated Fontan patients between 2014 and 2021. Seventeen patients were operated on with a mean age and body weight of 9.1 ± 5.5 years and 28.6 ± 14.6 kg. RESULTS Sixteen patients (94%) were palliated as univentricular physiology with hypoplasia of one of the ventricles. One patient (6%) with well-developed two ventricles with double outlet right ventricle and complete atrioventricular septal defect had straddling of the chordae prohibiting a biventricular repair. All of the patients had cavopulmonary anastomosis before Fontan completion, except one case. Fenestration was performed in all cases. Postoperative mean pulmonary artery pressures and arterial oxygen saturation levels at follow-up were 10 ± 2.4 mmHg and 91.3 ± 2.7%, respectively. Mean duration of pleural drainage was 5.4 ± 2.3 days. All of the fenestrations are patent at a mean follow-up period of 4.8 ± 7.7 years, except one case. Any morbidity and mortality were not encountered. CONCLUSIONS Early outcomes of intraextracardiac fenestrated FP are encouraging. This procedure may improve the results in a patient population who should be palliated as univentricular physiology, especially in cases with complex cardiac anatomy.
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Affiliation(s)
- Baran Şimşek
- Department of Cardiovascular Surgery, Medicana International Hospital, Istanbul, Turkey
| | - Arda Özyüksel
- Department of Cardiovascular Surgery, Medicana International Hospital, Istanbul, Turkey.,Department of Cardiovascular Surgery, Biruni University, Istanbul, Turkey
| | - Şener Demiroluk
- Department of Anesthesiology, Medicana International Hospital, Istanbul, Turkey
| | - Murat Saygı
- Department of Pediatric Cardiology, Medicana International Hospital, Istanbul, Turkey
| | - Mehmet S Bilal
- Department of Cardiovascular Surgery, Medicana International Hospital, Istanbul, Turkey
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Abstract
A Fontan circulation requires a series of three-staged operations aimed to palliate patients with single-ventricle CHD. Currently, the most frequent technique is the extracardiac total cavopulmonary connection, an external conduit connecting the IVC and right pulmonary artery, bypassing the right side of the heart. Fontan candidates must meet strict criteria; they are assessed utilising both cardiac catheterisation and cardiac magnetic resonance. Postoperatively, treatment protocols prioritise antibiotic prophylaxis, diuretics, angiotensin-converting enzyme inhibitors, anticoagulation, and oxygen therapy with fluid restriction and a low-fat diet. These measures aim to reduce length of stay in the ICU and hospital by preventing acute complications such as infection, venous thromboembolism, low cardiac output, pleural effusion, and acute kidney injury. Late complications of a Fontan procedure include circulation failure, protein-losing enteropathy, plastic bronchitis, and Fontan-associated liver disease. The definitive management is cardiac transplantation, with promising innovations in selective embolisation of lymphatic vessels and Fontan-specific ventricular assist devices. Further research assessing current protocols in the perioperative management of Fontan patients would be beneficial for standardising current practice and improving outcomes.
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Abstract
Previous reports have identified risk factors associated with development of post-Fontan protein-losing enteropathy. Less is known about the economic impact and resource utilisation required for post-Fontan protein-losing enteropathy in the current era. We conducted a single-centre retrospective study to assess the impact of post-Fontan protein-losing enteropathy on transplant-free survival. We also described resource utilisation and treatment variations among post-Fontan protein-losing enteropathy patients. Children who received care at our centre between 2009 and 2017 after the Fontan surgery were eligible. Initial admissions for the Fontan operative procedure were excluded. Demographics, hospital admissions, resource utilisation, medications and charges were reviewed. Patients were divided into two groups based on the presence of post-Fontan protein-losing enteropathy. Of the 343 patients screened, 147 met the eligibility criteria. Of these, 28 (19%) developed protein-losing enteropathy. After adjusting for follow-up duration, the protein-losing enteropathy group had higher number of encounters (2.15 ± 2.16 versus 1.47 ± 2.56, p 0.002), hospital length of stay (days) (25 ± 51.3 versus 11.4 ± 41.7, p < 0.0001) and total charges (2018US$) (388,489 ± 759,859 versus 202,725 ± 1,076,625, p < 0.0001). Encounters for patients with protein-losing enteropathy utilised more therapies. Among those with protein-losing enteropathy, use of digoxin was associated with slightly decreased odds for mortality and/or transplant (0.95, confidence interval 0.90-0.99, p 0.021). The 10-year transplant-free survival for patients with/without protein-losing enteropathy was 65.7/97.3% (p 0.002), respectively. Post-Fontan protein-losing enteropathy is associated with reduced 10-year transplant-free survival, higher resource utilisation, charges and medication use compared with the non-protein-losing enteropathy group. Practice variation among post-Fontan protein-losing-enteropathy patients is common. Further larger studies are needed to assess the impact of standardisation on the well-being of children with post-Fontan protein-losing enteropathy.
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Talwar S, Sengupta S, Choudhary SK. The intra-extracardiac Fontan: preliminary results. Indian J Thorac Cardiovasc Surg 2020; 36:193-198. [PMID: 33061125 PMCID: PMC7525840 DOI: 10.1007/s12055-019-00862-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 08/01/2019] [Accepted: 08/06/2019] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE Since the intra-extracardiac Fontan (IECF) was popularized by Jonas in 2008, its claimed advantages over the traditional extracardiac or lateral tunnel Fontan are simplicity, suitability for nearly all subsets, flow characteristics, low risk of sinus node artery injury, and possibly, a lower incidence of arrhythmias. In this paper, we present our early experience with this modification of the Fontan operation. METHODS Between 2009 and 2018, 10 patients underwent IECF on cardiopulmonary bypass (CPB) and cardioplegic arrest at our institute. Analysis of preoperative, intraoperative, and early follow-up results was performed. A polytetrafluoroethylene (PTFE) graft was sutured proximally to the orifice of the inferior vena cava (IVC) and distally to the ipsilateral bidirectional superior cavopulmonary (BSCP) junction. RESULTS Nine patients had undergone a previous BSCP connection, and one patient had a primary IECF. Diagnoses were double outlet right ventricle (n = 2), unbalanced atrioventricular septal defect with associated atrioventricular valve regurgitation (n = 3), single ventricle with anomalies of cardiac situs (n = 2), and tricuspid atresia with borderline pulmonary arteries (n = 1) or tricuspid atresia with borderline pulmonary artery pressures (n = 2). Median aortic cross-clamp and CPB times were 42 min and 82 min respectively. There were no early or late deaths. Median intensive care stay was 3 days (1 to 23 days). There were no arrhythmias. Mean duration of pleural effusions was 9.5 (median 5.5) days. There were no arrhythmias at a median follow-up of 5 years (range 1 month to 9.3 years). CONCLUSION The IECF is simple, particularly at reoperations, in borderline patients and those needing concomitant intracardiac procedures. Early results are promising. These patients need constant surveillance.
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Affiliation(s)
- Sachin Talwar
- Cardiothoracic Centre, Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Sanjoy Sengupta
- Cardiothoracic Centre, Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Shiv Kumar Choudhary
- Cardiothoracic Centre, Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, 110029 India
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Talwar S, Marathe SP, Choudhary SK, Airan B. Where are we after 50 years of the Fontan operation? Indian J Thorac Cardiovasc Surg 2020; 37:42-53. [PMID: 33584026 DOI: 10.1007/s12055-019-00906-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/02/2019] [Accepted: 11/08/2019] [Indexed: 01/11/2023] Open
Abstract
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.
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Affiliation(s)
- Sachin Talwar
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029 India
| | | | - Shiv Kumar Choudhary
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Balram Airan
- Mahatma Gandhi Hospital, Mahatma Gandhi University of Medical Sciences Technology, Jaipur, India
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Kilcoyne MF, Stevens RM, Mahan V, Gray P, Moulick AN. Fontan procedure: Early outcomes of 87 consecutive patients in a tertiary care center. J Card Surg 2020; 35:738-739. [PMID: 32073683 DOI: 10.1111/jocs.14462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Al Absi and colleagues report their early results of the Fontan procedure in 87 consecutive patients between August 2008 and July 2017 in a tertiary care hospital. The use of the intra/extracardiac fenestration is a promising modification because it is unlikely to be occluded by surrounding tissue and may be associated with decreased pleural effusions, length of hospital stay, and incidence of postoperative arrhythmias.
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Affiliation(s)
- Maxwell F Kilcoyne
- Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Randy M Stevens
- Department of Cardiothoracic Surgery, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
| | - Vicki Mahan
- Department of Cardiothoracic Surgery, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
| | - Patrick Gray
- Department of Pediatric Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Achintya N Moulick
- Department of Cardiothoracic Surgery, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
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Extracardiac Versus Lateral Tunnel Fontan: A Meta-Analysis of Long-Term Results. Ann Thorac Surg 2019; 107:837-843. [DOI: 10.1016/j.athoracsur.2018.08.041] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 07/20/2018] [Accepted: 08/20/2018] [Indexed: 11/22/2022]
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Abstract
The care of children with hypoplastic left heart syndrome is constantly evolving. Prenatal diagnosis of hypoplastic left heart syndrome will aid in counselling of parents, and selected fetuses may be candidates for in utero intervention. Following birth, palliation can be undertaken through staged operations: Norwood (or hybrid) in the 1st week of life, superior cavopulmonary connection at 4-6 months of life, and finally total cavopulmonary connection (Fontan) at 2-4 years of age. Children with hypoplastic left heart syndrome are at risk of circulatory failure their entire life, and selected patients may undergo heart transplantation. In this review article, we summarise recent advances in the critical care management of patients with hypoplastic left heart syndrome as were discussed in a focused session at the 12th International Conference of the Paediatric Cardiac Intensive Care Society held on 9 December, 2016, in Miami Beach, Florida.
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Sinha L, Ozturk M, Zurakowski D, Yerebakan C, Ramakrishnan K, Matisoff A, Ruth J, Jonas RA, Sinha P. Intra-Extracardiac Versus Extracardiac Fontan Modifications: Comparison of Early Outcomes. Ann Thorac Surg 2018; 107:560-566. [PMID: 30273570 DOI: 10.1016/j.athoracsur.2018.07.080] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 06/20/2018] [Accepted: 07/25/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND The intra-extracardiac (IE) Fontan modification has advantages over the lateral tunnel modification. A direct comparison of IE to the extracardiac (EC) modification so far has not been done. This study compared IE to EC Fontan with respect to early postoperative outcomes. METHODS We retrospectively compared outcomes of the Fontan operation using the IE or EC conduit modification between January 2012 and December 2016. IE and EC groups were compared using univariate and multivariable regression analysis. To eliminate the confounding effects of fenestration, repeat intergroup comparison was performed after excluding nonfenestrated patients. RESULTS There were 81 patients grouped according to Fontan modification into the IE group (n = 43) or EC group (n = 38). The Fontan was fenestrated in 100% of the IE group but in only 55% of the EC group (p < 0.001). Cardiopulmonary bypass time was shorter for the IE group (74 vs 103, p < 0.001) The IE patients had median cross-clamp time of 34 minutes, whereas only 2 patients in the EC group required cross-clamping (35 and 95 minutes; p < 0.001). The IE group had significantly shorter median duration of pleural effusion (8 days vs 11 days, p = 0.007) and hospital length of stay (9 days vs 13 days, p = 0.001) than the EC group. Multivariable linear regression analysis revealed that the IE modification was independently associated with reduced duration of pleural effusion (p = 0.004) and hospital length of stay (p = 0.003). Presence of any unfavorable hemodynamics on preoperative assessment was also associated with longer duration of pleural effusion and hospital length of stay for patients with fenestration. CONCLUSIONS The IE Fontan modification may be associated with reduced duration of postoperative pleural effusion and hospital length of stay compared with the EC modification.
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Affiliation(s)
- Lok Sinha
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC
| | - Mahmut Ozturk
- Marmara University School of Medicine, Istanbul, Turkey
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Anesthesia, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Can Yerebakan
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC
| | - Karthik Ramakrishnan
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC
| | - Andrew Matisoff
- Department of Anesthesiology, Children's National Health System, Washington, DC
| | - John Ruth
- Department of Anesthesiology, Children's National Health System, Washington, DC
| | - Richard A Jonas
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC
| | - Pranava Sinha
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC.
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Abstract
The Fontan procedure is the final procedure in staged palliation for patients with functional single-ventricle physiology. The goal of the procedure is to separate systemic and pulmonary blood flow by directing systemic venous return through the Fontan connection to the pulmonary arteries and the lungs without ventricular contribution. Following the procedure, pulmonary blood flow is completely passive and dependent on pressure gradients, resulting in complex postoperative cardiopulmonary interactions. Understanding the physiology is essential to effectively manage these patients. Critical care nurses caring for patients after a Fontan procedure must understand preoperative data, risk factors, and unique postoperative physiology so they can anticipate specific postoperative problems, recognize trends in clinical status, and develop an appropriate plan of care. This paper reviews the first 2 stages of single-ventricle palliation, relevant modifications to the Fontan procedure, important preoperative cardiac catheterization data, common postoperative problems, and outcomes after the Fontan procedure.
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Affiliation(s)
- Melissa Beaudet Jones
- Melissa Beaudet Jones is a nurse practitioner and ventricular assist device coordinator in the cardiac intensive care unit at Children's National Health System in Washington, DC.
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Windsor J, Townsley MM, Briston D, Villablanca PA, Alegria JR, Ramakrishna H. Fontan Palliation for Single-Ventricle Physiology: Perioperative Management for Noncardiac Surgery and Analysis of Outcomes. J Cardiothorac Vasc Anesth 2017; 31:2296-2303. [DOI: 10.1053/j.jvca.2017.04.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Indexed: 12/14/2022]
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Li D, Fan Q, Hirata Y, Ono M, An Q. Arrhythmias After Fontan Operation with Intra-atrial Lateral Tunnel Versus Extra-cardiac Conduit: A Systematic Review and Meta-analysis. Pediatr Cardiol 2017; 38:873-880. [PMID: 28271152 DOI: 10.1007/s00246-017-1595-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 02/21/2017] [Indexed: 02/05/2023]
Abstract
Current studies on the incidence of arrhythmias after the intra-atrial lateral tunnel (ILT) Fontan operation and the extra-cardiac conduit (ECC) Fontan operation are limited, with controversial results. This systematic review aimed to compare the prevalence of arrhythmias in patients who underwent ECC or ILT Fontan. Relevant studies comparing the incidence of arrhythmias and pacemaker implantation in ILT with ECC were identified through a literature search using MEDLINE, EMBASE, and the cochrane central register of controlled trials. The outcome measures included baseline characteristics, early (≤30 days) and late (>30 days) arrhythmias and pacemaker implantation. 16 publications involving 3499 patients were included. In the meta-analysis, although the overall risk of early arrhythmias was lower for the ILT group, statistically, no significant difference was observed (odds ratio [OR] 0.78; 95% confidence interval [CI] 0.61-1.01; p = 0.06). Similarly, there was no significant difference between the two cohorts in the incidence of postoperative permanent pacemaker therapy (OR 1.36; 95% CI 0.86-2.14; p = 0.19). However, we found significantly increased incidence of late arrhythmias in ILT group compared with ECC group (OR 1.96; 95% CI 1.64-2.35; p < 0.01). Although our systematic review and meta-analysis suggested that there was no significant difference in early arrhythmias and in pacemaker implantation between the ILT and ECC groups, ECC procedure could significantly lower the risk of late arrhythmias after Fontan surgery. Given that some limitations cannot be overcome, well-designed randomized controlled trials are needed to confirm our findings.
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Affiliation(s)
- Dongxu Li
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Qiang Fan
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Yasutaka Hirata
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Qi An
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China.
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Zheng J, Li Z, Li Q, Li X. Meta-analysis of Fontan procedure. Herz 2017; 43:238-245. [DOI: 10.1007/s00059-017-4553-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 02/03/2017] [Accepted: 02/09/2017] [Indexed: 11/30/2022]
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Ortiz-Vázquez M, Espinoza-Blanco O, Ramírez-Marroquín S, Calderón-Colmenero J, García-Montes JA, Cervantes-Salazar J. [Comparison between patients undergoing Fontan operation with or without cardiopulmonary bypass]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2016; 86:1-10. [PMID: 26830073 DOI: 10.1016/j.acmx.2015.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 12/03/2015] [Accepted: 12/06/2015] [Indexed: 11/17/2022] Open
Abstract
Fontan operation is the final palliative stage of patients with univentricular hearts. Cardiopulmonary bypass (CPB) decreases ventricular performance and increases pulmonary artery pressures in the post operative recovery period. It seems that Fontan operation performed without CPB decreases short term morbidity and intra hospitalary length of stay. OBJETIVE Compare outcome in Fontan patients who have undergone surgery with or without CPB. METHOD This is a retrospective review of patients undergoing Fontan operation from january 2009 to december 2012. Patients were grouped according to CPB use and comparative analyses were done. RESULTS Ten patients were operated without CPB use. There was a discrepancy between age in both groups, being younger in the no CPB group. Around 80% of patients in both groups had a staged procedure. A 18mm graft was used in half of the cases; a fenestration was created in all cases. Length of stay was equal in both groups, there was less need of pharmacologic support and nitric oxide use in patients without CPB use. No deaths were reported also in this group. At folllow up, most patients had a class i functional status. CONCLUSIONS In our experience, Fontan operation without CPB has similar outcomes compared with CPB use.
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Affiliation(s)
- Marlo Ortiz-Vázquez
- Cirugía de Malformaciones Congénitas del Corazón, Instituto Nacional de Cardiología Dr. Ignacio Chávez, Facultad de Medicina, División de estudios de posgrado, UNAM, México, D.F., México
| | - Osbaldo Espinoza-Blanco
- Cirugía de Malformaciones Congénitas del Corazón, Instituto Nacional de Cardiología Dr. Ignacio Chávez, Facultad de Medicina, División de estudios de posgrado, UNAM, México, D.F., México
| | - Samuel Ramírez-Marroquín
- Cirugía de Malformaciones Congénitas del Corazón, Instituto Nacional de Cardiología Dr. Ignacio Chávez, Facultad de Medicina, División de estudios de posgrado, UNAM, México, D.F., México
| | - Juan Calderón-Colmenero
- Cirugía de Malformaciones Congénitas del Corazón, Instituto Nacional de Cardiología Dr. Ignacio Chávez, Facultad de Medicina, División de estudios de posgrado, UNAM, México, D.F., México
| | - Jose Antonio García-Montes
- Cirugía de Malformaciones Congénitas del Corazón, Instituto Nacional de Cardiología Dr. Ignacio Chávez, Facultad de Medicina, División de estudios de posgrado, UNAM, México, D.F., México
| | - Jorge Cervantes-Salazar
- Cirugía de Malformaciones Congénitas del Corazón, Instituto Nacional de Cardiología Dr. Ignacio Chávez, Facultad de Medicina, División de estudios de posgrado, UNAM, México, D.F., México.
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He D, Olivieri LJ, Jonas RA, Sinha P. Palliation of Truncus Arteriosus Associated With Complete Atrioventricular Canal--Results of Single Ventricle Palliation. World J Pediatr Congenit Heart Surg 2015; 6:663-6. [PMID: 26467884 DOI: 10.1177/2150135115578180] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Truncus arteriosus associated with complete atrioventricular canal defect is rare and continues to be a surgical challenge with high morbidity and mortality. In the absence of extension of the ventricular septal defect to the outlet septum, biventricular repair is precluded, and single ventricle palliation remains the only option. We present our experience with five patients with truncus arteriosus and complete atrioventricular canal defect who underwent single ventricular palliation. METHODS Five patients with truncus arteriosus and complete atrioventricular canal defect managed along the single ventricle palliation pathway were retrospectively reviewed. Demographic, echocardiographic, cardiac catheterization, and perioperative data were analyzed. RESULTS All patients underwent neonatal palliation tailored to their anatomy (excision of pulmonary arteries from the common trunk and systemic to pulmonary artery shunt in two patients, excision of pulmonary artery and right ventricle to pulmonary artery conduit in two patients, and bilateral branch pulmonary artery bands in one patient). There were two early deaths after neonatal palliation. At a median follow-up of 210 days (interquartile range 1,210 days), all three survivors have undergone second-stage palliation. Of these patients, one is interstage II to III, and two patients have completed their Fontan procedure and are doing well. CONCLUSION Truncus arteriosus with complete atrioventricular canal defect is a rare combination of defects. Single ventricle palliation pathway with a tailored neonatal approach may be employed for patients with uncommitted ventricular septal defects.
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Affiliation(s)
- Dingchao He
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC, WA, USA
| | - Laura J Olivieri
- Department of Cardiology, Children's National Health System, Washington, DC, WA, USA
| | - Richard A Jonas
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC, WA, USA
| | - Pranava Sinha
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC, WA, USA
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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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Persistent fenestration may be a marker for physiologic intolerance after Fontan completion. J Thorac Cardiovasc Surg 2014; 148:2532-8. [DOI: 10.1016/j.jtcvs.2014.06.062] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 05/31/2014] [Accepted: 06/27/2014] [Indexed: 11/19/2022]
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Mavroudis C, Stulak JM, Ad N, Siegel A, Giamberti A, Harris L, Backer CL, Tsao S, Dearani JA, Weerasena N, Deal BJ. Prophylactic atrial arrhythmia surgical procedures with congenital heart operations: review and recommendations. Ann Thorac Surg 2014; 99:352-9. [PMID: 25442995 DOI: 10.1016/j.athoracsur.2014.07.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 07/03/2014] [Accepted: 07/09/2014] [Indexed: 10/24/2022]
Abstract
Specific congenital heart anomalies significantly increase the risk for late atrial arrhythmias, raising the question whether prophylactic arrhythmia operations should be incorporated into reparative open heart procedures. Currently no consensus exists regarding standard prophylactic arrhythmia procedures. Questions remain concerning the arrhythmia-specific lesions to perform, energy sources to use, need for atrial appendectomy, and choosing a right, left, or biatrial Maze procedure. These considerations are important because prophylactic arrhythmia procedures are performed without knowing if the patient will actually experience an arrhythmia. This review identifies congenital defects with a risk for the development of atrial arrhythmias and proposes standardizing lesion sets for prophylactic arrhythmia operations.
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Affiliation(s)
- Constantine Mavroudis
- Johns Hopkins Children's Heart Surgery, Florida Hospital for Children, Orlando, Florida.
| | - John M Stulak
- Division of Cardiovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Niv Ad
- Inova Fairfax Hospital, Cardiac Surgery Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Allison Siegel
- Johns Hopkins Children's Heart Surgery, Florida Hospital for Children, Orlando, Florida
| | - Alessandro Giamberti
- Pediatric and Adult Congenital Heart Surgery, IRCSS Policlinico San Donato, San Donato M.se (MI), Italy
| | - Louise Harris
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto Congenital Cardiac Centre for Adults, Toronto, Ontario, Canada
| | - Carl L Backer
- Cardiovascular-Thoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Sabrina Tsao
- Division of Cardiology and the Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Joseph A Dearani
- Division of Cardiovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Nihal Weerasena
- Division of Cardiothoracic Surgery, The General Infirmary, Leeds, United Kingdom
| | - Barbara J Deal
- Division of Cardiology and the Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Comparison of fenestrated and nonfenestrated patients undergoing extracardiac Fontan. Ann Thorac Surg 2014; 97:924-31; discussion 930-1. [PMID: 24495416 DOI: 10.1016/j.athoracsur.2013.11.041] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 10/29/2013] [Accepted: 11/11/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND The purpose of this study is to compare morbidity and mortality between fenestrated (F, 61 patients) and nonfenestrated (NF, 54 patients) extracardiac Fontan patients during two eras from July 1995 to December 2010: era 1(1995 to 2004) and era 2 (2005 to 2010). METHODS Variables evaluated included morphology, hemodynamics, chest tube volume and duration, intensive care and hospital stay, oxygen saturation, neurologic events, rhythm, and readmissions for chylous effusions. Follow-up in 114 hospital survivors was longer in the nonfenestrated cohort (F, 5.0 ± 3.3 years; NF, 7.1 ± 4.6 years; p < 0.005). RESULTS Cohorts were similar in body size, morphology, and hemodynamics. Fenestration in hypoplastic left heart syndrome was appreciatively higher in era 2. Bypass time (F, 69 ± 27 minutes; NF, 57 ± 21 minutes) and conduit size (F, 18.8 mm; NF, 19.1 mm) were similar. There was 1 early nonfenestrated Fontan death (1 of 54; 2%) and 4 late deaths (F, 2 of 61, 5%; NF, 2 of 53, 4%; p = 0.86). Room air saturation was higher in NF patients (F, 89%; NF, 94%; p < 0.05). Total chest tube volume was similar, but fenestration was associated with greater chest tube drainage among hypoplastic left heart patients (HLHS, 5,582 ± 3,286 mL; non-HLHS, 3,405 ± 2,533 mL; p = 0.06; odds ratio; 2.0). Readmission to treat chylous effusions, loss of sinus rhythm, actuarial freedom from death, all neurologic events, pacemaker insertion, and Fontan takedown were similar in both cohorts. CONCLUSIONS Fenestration was associated with lower discharge oxygen saturations, but late outcomes in fenestrated and nonfenestrated patients are equivalent.
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