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J Thorac Cardiovasc Surg 2006;132:1054-1063
© 2006 The American Association for Thoracic Surgery

Surgery for Congenital Heart Disease

The extracardiac conduit Fontan operation using minimal approach extracorporeal circulation: Early and midterm outcomes

^a Division of Pediatric Cardiac Surgery, Stanford University School of Medicine, Stanford, Calif
^b Department of Pediatric Cardiology and Cardiothoracic Surgery, Children's Hospital Central California, Madera, Calif
^c Division of Pediatric Cardiology, University of California San Francisco, San Francisco, Calif
^d Department of Pediatric Cardiology and Cardiothoracic Surgery, Children's Hospital Oakland, Oakland, Calif
^e Department of Pediatric Cardiothoracic Surgery, Sutter Medical Center, Sacramento, Calif.

Read at the Eighty-fifth Annual Meeting of The American Association for Thoracic Surgery, San Francisco, Calif, April 10-13, 2005.

Received for publication September 11, 2005; revisions received May 2, 2006; accepted for publication May 8, 2006.

^_* Address for reprints: Ed Petrossian, MD, Children's Hospital Central California, 9300 Valley Children's Place, Madera, CA 93638-8762. (Email: epetrossian{at}childrenscentralcal.org).

OBJECTIVE: Our approach to the extracardiac conduit Fontan operation has evolved over time from full-pump, to partial-pump, to completely off-pump. This study is designed to report our overall experience with the extracardiac conduit Fontan operation and to evaluate the evolution in bypass technique on postoperative outcomes.

METHODS: From September 1992 to April 2005, 285 patients, median age 4.5 years (1.4-44 years), median weight 16 kg (9.4-94 kg), underwent a primary extracardiac conduit Fontan procedure. Early and late outcomes were analyzed for the entire cohort and for 2 patient groups depending on whether an oxygenator was used in the bypass circuit (166 patients; 58%) or not (119 patients; 42%).

RESULTS: Early failure (including death and takedown) occurred in 7 patients (2.5%). Prevalence of new early postoperative sinus node dysfunction necessitating a permanent pacemaker was 0.4%, and that of new tachyarrhythmias necessitating discharge home on a regimen of antiarrhythmia medications was 2.5%. Ten-year actuarial freedom from Fontan failure, new sinus node dysfunction necessitating a permanent pacemaker, and reoperation for conduit thrombosis or stenosis was 90%, 96%, and 98%, respectively. Fenestration rate was lower (P = .001) in the no-oxygenator group (8%) than in the oxygenator group (25%). Patients in the no-oxygenator group had lower intraoperative Fontan pressure (12.0 ± 2.3 vs 13.5 ± 2.4 mm Hg, P < .001), common atrial pressure (4.6 ± 1.8 vs 5.3 ± 1.8 mm Hg, P = .003), and transpulmonary gradient (7.5 ± 2.1 vs 8.3 ± 2.2 mm Hg, P = .013) than did the oxygenator group.

CONCLUSIONS: The extracardiac conduit Fontan operation coupled with minimal use of extracorporeal circulation is associated with favorable intraoperative hemodynamics, low fenestration rate, minimal risk of thrombosis or stenosis, and minimal early and late rhythm disturbance.

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