De novo creation of fenestration and stent implantation for failed extracardiac conduit Fontan operation

Transcatheter Fontan Fenestration Closure: Sustained Improvements in Oxygen Saturation with Minimal Morbidity and Mortality

Fontan fenestration decreases central venous pressure and preserves cardiac output while decreasing systemic oxygen saturation. Transcatheter fenestration closure increases oxygen saturation, though the persistence of this increase and the long-term incidence of adverse outcomes such as death and heart transplant remain unknown. We describe immediate and long-term clinical and adverse outcomes following fenestration closure. Catheterization, echocardiogram, and clinic reports were reviewed following transcatheter Fontan fenestration closure. Data were reported as n (%) and median (IQR). Continuous variables were compared using Wilcoxon ranked sum test. 51 patients had fenestration closure 0.9 (0.7-1.5) years following extracardiac Fontan operation. Most (84%) were closed with Amplatzer Septal Occluders. Systemic O₂ saturation immediately increased from 87 (83-89) to 95 (94-97)%, P < 0.05. Cardiac index decreased from 4 (3-5) to 2.9 (2.6-3.5) L/min/m². Fontan pressure and pulmonary vascular resistance were not significantly changed. Clinical follow-up duration for all patients was 7.3 (range 1.3-16) years. Oxygen saturation at last follow-up was 94.5 (92-97)% and did not decrease over time (P < 0.05). One patient (2%) developed protein losing enteropathy, 1 (2%) had heart transplant, and 1 (2%) patient died 9.4 years following fenestration closure. No patient required fenestration re-creation following closure. Transcatheter Fontan fenestration closure leads to sustained increases in systemic oxygen saturation and a low incidence of adverse outcomes such as death and transplant. Further study comparing fenestration closure to non-closure and longer follow-up duration are required to determine if there is a survival benefit to fenestration closure.

"Taking in the Waist": Adjusting the Size of a Stented Fontan Fenestration

Early spontaneous closure of a fenestration following Fontan palliation may complicate the postoperative management of such patients. The creation of a fenestration in the catheterization laboratory with an intravascular stent may improve these patients' hemodynamic status. The aim of this study is to present a new technique to reduce the diameter of stented Fontan fenestrations in those patients in whom the stent diameter is functionally made too large.

Fenestration in extracardiac conduits in children after modified Fontan operation by implantation of stent grafts

Three patients (ages 3, 5, and 8 years) with various forms of functionally univentricular heart lesions received a total cavopulmonary connection with an extracardiac conduit as a final reconstructive procedure. Failure of the Fontan circulation occurred immediately after surgery because of spontaneous closure of surgical fenestrations in two children and absent fenestration in one. As an emergency procedure, in all patients the conduit was perforated by transcatheter intervention in order to create a connection to the anatomical right atrium. Following balloon dilatation of the perforated conduit, in all three patients covered stent grafts were placed in the newly created defect to attain a reliable communication. Patency of the fenestration was demonstrated by angiogram and any leakage was ruled out. Cardiac output improved and severe pleural effusion and ascites subsided. Right-to-left shunt could be demonstrated by echocardiography at follow-up after 7 months (median) in all three patients. Oxygen saturation remained stable between 85 and 90%. These preliminary results suggest that stent graft fenestration can serve as a valuable tool in failing Fontan circulation, particularly in patients with an extracardiac conduit. Covered stents have the potential to reduce the acute risk of bleeding and they help to prevent early spontaneous closure of the newly created fenestration.