Intracardiac Cavopulmonary Connection in Patients with Univentricular Heart Using Intra-atrial Lateral Tunnel and Intra-atrial Conduit Techniques
DOI:
https://doi.org/10.1532/HSF98.20101011Abstract
Background: In this study, we analyzed the time course of hemodynamic efficiency and follow-up in Fontan candidates who underwent the bidirectional Glenn procedure for staged intracardiac cavopulmonary connection (ICPC).
Methods: Between 1991 and 2008, 52 patients with univentricular heart (mean age, 3.3 years; range, 2-8 years; 27 female patients [51.9%]) underwent ICPC. The cardiac malformations were as follows: tricuspid atresia, 25 cases (48.0%); common ventricle, 16 cases (30.7%); and pulmonary atresia with intact ventricular septum, 11 cases (21.1%). The intracardiac cavopulmonary procedure was indicated for all 52 cases. In 42 patients (80.7%), an intra-atrial lateral tunnel was constructed with a bovine pericardium patch. In the last 10 consecutive cases (19.3%), we performed a modified surgical technique in which we implanted an intra-atrial corrugated bovine pericardium tube sutured around the superior and inferior vena cava ostium. In all cases, a 4-mm fenestration was made to reduce the intratunnel pressure. All 52 patients had previously undergone a Glenn operation.
Results: There were 2 hospital deaths (3.8%) and no recorded late deaths. During the follow-up, all patients were medicated with antiplatelet drugs. To evaluate the hemodynamic performance, we used Doppler echocardiography, computed tomography, and magnetic nuclear resonance studies. There were no prosthesis thromboses during this followup period. To evaluate cardiac arrhythmias, we conducted a Holter study. The last 10 patients with an intra-atrial conduit (IAC) presented with sinus rhythm and no arrhythmias during the last 4 years. The 50 surviving patients (96.1%) have been followed up for 6 to 204 months; all these patients are free of reoperation.
Conclusion: The Glenn operation, which is performed at an early age, prepares the pulmonary bed to receive the ICPC. The midterm results of the intracardiac Fontan procedure seem to be good. The modified surgical procedure (IAC) can be a good alternative technique to the Fontan procedure in suitable patients.
References
Alejos JC, Williams RG, Jarmakani KM, et al. 1995. Factors influencing survival in patients undergoing the bidirectional Glenn anastomosis. Am J Cardiol 75:1048-50.nBlaufox AD, Sleeper LA, Bradley DJ, et al. 2008. Functional status, heart rate, and rhythm abnormalities in 521 Fontan patients 6 to 18 years of age. Thorac Cardiovasc Surg 136:100-7.nBridges ND, Jonas RA, Mayer JE, Flanagan MF, Keane JF, Castaneda AR. 1990. Bidirectional cavopulmonary anastomosis as interim palliation for high-risk Fontan candidates. Early results. Circulation 82:IV170-6.nBrown JW, Ruzmetov M, Deschner BW, Rodefeld MD, Turrentine MW. 2010. Lateral tunnel Fontan in the current era: is it still a good option? Ann Thorac Surg 89:556-62.nBurke RP, Jacobs JP, Ashraf MH, Aldousany A, Chang AC. 1997. Extracardiac Fontan operation without cardiopulmonary bypass. Ann Thorac Surg 63:1175-7.nCetta F, Feldt RH, O'Leary PW, et al. 1996. Improved early morbidity and mortality after Fontan operation: the Mayo Clinic experience, 1987 to 1992. J Am Coll Cardiol 28:480-6.nde Leval MR. 2010. Evolution of the Fontan-Kreutzer procedure. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 13:91-5.nde Leval MR, Kilner P, Gewillig M, Bull C. 1988. Total cavopulmonary connection: a logical alternative to atriopulmonary connection for complex Fontan operation: experimental studies and early clinical experience. J Thorac Cardiovasc Surg 96:682-95.nDouville EC, Sade RM, Fyfe DA. 1991. Hemi-Fontan operation in surgery for single ventricle: a preliminary report. Ann Thorac Surg 51:893-9.nFogel MA, Weinberg PM, Fellows KE, Hoffman EA. 1995. A study in ventricular-ventricular interaction. Single right ventricles in a dual-chamber circulation. Circulation 92:219-30.nFontan F, Baudet E. 1971. Surgical repair of tricuspid atresia. Thorax 26:240-8.nFujii Y, Sano S, Kotani Y, et al. 2009. Midterm to long-term outcome of total cavopulmonary connection in high-risk adult candidates. Ann Thorac Surg 87:562-70.nGewilling M, Wyse RK, de Leval MR, Deanfield JE. 1992. Early and late arrhythmias after the Fontan operation: predisposing factors and clinical consequences. Br Heart J 67:72-9.nGiannico S, Corno A, Marino B, et al. 1992. Total extracardiac right heart bypass. Circulation 86:II110-7.nJonas RA, Castaneda AR. 1988. Modified Fontan procedure: atrial baffle and systemic venous to pulmonary artery anastomotic techniques. J Card Surg 3:91-6.nKim WH, Lim HG, Lee JR, et al. 2005. Fontan conversion with arrhythmia surgery. Eur J Cardiothorac Surg 27:250-7.nKreutzer GO, Schlichter AJ, Kreutzer C. 2010. The Fontan/Kreutzer procedure at 40: an operation for the correction of tricuspid atresia. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 13:84-90.nMaluf M, Andrade JC, Catani R, et al. 1994. Avaliação dos resultados tardios da Operação de derivação cavo-pulmonar bidirecional no tratamento paliativo de cardiopatias cong?nitas com câmara ventricular única funcionante. Rev Bras Cir Cardiovasc 9:95-103.nMaluf M, Mangia C, Bertuccez J, et al. 1999. Estudo comparativo de associação de ultrafiltração convencional e modificada na correção de cardiopatias cong?nitas de alto risco. Rev Bras Cir Cardiovasc 14:221-36.nMarcelletti C, Corno A, Giannico S, Marino B. 1990. Inferior vena cavapulmonary artery extracardiac conduit: a new form of right heart bypass. J Thorac Cardiovasc Surg 100:228-32.nMasuda M, Kado H, Shiokawa Y, et al. 1998. Clinical results of the staged Fontan procedure in high-risk patients. Ann Thorac Surg 65:172-5.nMcElhinney DB, Petrossian E, Reddy VM, Hanley FL. 1998. Extracardiac conduit Fontan procedure without cardiopulmonary bypass. Ann Thorac Surg 66:1826-8.nNagaki M, Senzaki H, Masutani S, et al. 2000. Ventricular energetics in Fontan circulation: evaluation with a theoretical model. Pediatr Int 42:651-7.nNakata S, Imai Y, Takanashi Y, et al. 1984. A new method for the quantitative standardization of cross-sectional areas of the pulmonary arteries in congenital heart diseases with decreased pulmonary blood flow. J Thorac Cardiovasc Surg 88:610-9.nPaulista PP, Souza LCB, Chaccur P, et al. 2003. Extracardiac conduit in total cavopulmonary connection. Rev Bras Cir Cardiovasc 18:20-33.nPrigjian AK, Mendelsohn AM, Lupinetti FM, et al. 1993. Usefulness of the bidirectional Glenn procedure as staged reconstruction for the functional single ventricle. Am J Cardiol 71:959-62.nRobbers-Visser D, Miedema M, Nijveld A, et al. 2010. Results of staged total cavopulmonary connection for functionally univentricular hearts; comparison of intra-atrial lateral tunnel and extracardiac conduit. Eur J Cardiothorac Surg 37:934-41.nRosenthal DN, Friedman AH, Kleinman CS, Kopf GS, Rosenfeld LE, Hellenbrand WE. 1995. Thromboembolic complications after Fontan operations. Circulation 92:II287-93.nSievers HH, Onnasch DG, Lange PE, Bernhard A, Heintzen H. 1983. Dimensions of the great arteries, semilunar valve roots, and right ventricular outflow tract during growth: normative angiocardiographic data. Pediatr Cardiol 4:189-96.nTanoue Y, Sese A, Ueno Y, Jok K, Hijii T. 2001. Bidirectional Glenn procedure improves the mechanical efficiency of a total cavopulmonary connection in high-risk Fontan candidates. Circulation 103:2176-80.nTrusler GA, Williams WG, Cohen AJ, et al. 1990. William Glenn lecture. The cavopulmonary shunt. Evolution of a concept. Circulation 82:IV131-8.nWestphal FL, Maluf MA, Silva CM, Carvalho ACC, Buffolo E. 2001. Estudo angiográfico comparativo da artéria pulmonar no pré e pós-operatório de pacientes submetidos a operação de derivação cavopulmonar bidirecional. Rev Bras Cir Cardiovasc 16:305-20.n
