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The Journal of Thoracic and Cardiovascular Surgery, Vol 96, 682-695, Copyright © 1988 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
MR de Leval, P Kilner, M Gewillig and C Bull
To understand better the contribution of a right atrium in a valveless
atriopulmonary connection, we performed some basic hydrodynamic studies.
Pulsation of a valveless chamber in a simple continuous flow circuit was
found to generate turbulence and thereby to increase resistance to net
forward flow. Visualization of flow through cavities and around corners and
measurements of energy losses across nonpulsatile cavities, corners, and
stenoses indicated the importance of streamlining. These studies suggested
ways in which hydrodynamic designs of the Fontan circulation might be
improved. In parallel with these in vitro studies, we have developed a
modified approach to Fontan reconstruction that entails exclusion of most
or all of the right atrium (total cavopulmonary connection). The operation
consists of three parts: (1) end-to-side anastomosis of the superior vena
cava to the undivided right pulmonary artery; (2) construction of a
composite intraatrial tunnel with the use of the posterior wall of the
right atrium; and (3) use of a prosthetic patch to channel the inferior
vena cava to the enlarged orifice of the transected superior vena cava that
is anastomosed to the main pulmonary artery. The operation was performed in
20 patients between March 1987 and March 1988. The diagnoses were
double-inlet ventricle (11 patients), hypoplastic systemic or pulmonary
ventricle (seven patients), and absent right atrioventricular connection
(two patients). There were two early deaths and one late death. None of the
deaths was related to the actual procedure but rather to increased
pulmonary vascular resistance (two patients) or systemic ventricular
failure (one patient). Total cavopulmonary connections have the following
advantages: (1) They are technically simple and reproducible in any
atrioventricular arrangement and are away from the atrioventricular node;
(2) most of the right atrial chamber remains at low pressure, which reduces
the risk of early or late arrhythmias; (3) reduction of turbulence prevents
energy losses and should minimize the risk of atrial thrombosis; (4)
postoperative cardiac catheterization performed in 10 patients confirmed
these favorable flow patterns with minimal gradients throughout the
connections. These encouraging early results support the continuing use of
total cavopulmonary connection, at least for patients with a
nonhypertrophied right atrium.
ARTICLES
Total cavopulmonary connection: a logical alternative to atriopulmonary connection for complex Fontan operations. Experimental studies and early clinical experience
Hospital for Sick Children, London, England.
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J Monro The changing state of surgery for adult congenital heart disease Heart, February 1, 2005; 91(2): 139 - 140. [Abstract] [Full Text] [PDF]
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A.M. Sheikh, A.T.M. Tang, K. Roman, K. Baig, R. Mehta, J. Morgan, B. Keeton, J. Gnanapragasam, J.V. Vettukattil, A.P. Salmon, et al. The failing Fontan circulation: Successful conversion of atriopulmonary connections J. Thorac. Cardiovasc. Surg., July 1, 2004; 128(1): 60 - 66. [Abstract] [Full Text] [PDF]
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Y. Isomatsu, T. Shin'oka, G. Matsumura, N. Hibino, T. Konuma, M. Nagatsu, and H. Kurosawa Extracardiac total cavopulmonary connection using a tissue-engineered graft J. Thorac. Cardiovasc. Surg., December 1, 2003; 126(6): 1958 - 1962. [Abstract] [Full Text] [PDF]
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S. P. Kumar, C. S. Rubinstein, J. M. Simsic, A. B. Taylor, J. P. Saul, and S. M. Bradley Lateral tunnel versus extracardiac conduit fontan procedure: a concurrent comparison Ann. Thorac. Surg., November 1, 2003; 76(5): 1389 - 1397. [Abstract] [Full Text] [PDF]
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E. L. Bove, M. R. de Leval, F. Migliavacca, G. Guadagni, and G. Dubini Computational fluid dynamics in the evaluation of hemodynamic performance of cavopulmonary connections after the norwood procedure for hypoplastic left heart syndrome J. Thorac. Cardiovasc. Surg., October 1, 2003; 126(4): 1040 - 1047. [Abstract] [Full Text] [PDF]
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A. Eicken, S. Fratz, C. Gutfried, G. Balling, M. Schwaiger, R. Lange, R. Busch, J. Hess, and H. Stern Hearts late after fontan operation have normal mass, normal volume, and reduced systolic function: A magnetic resonance imaging study J. Am. Coll. Cardiol., September 17, 2003; 42(6): 1061 - 1065. [Abstract] [Full Text] [PDF]
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J. L. Monro, C. Alexiou, A. P. Salmon, and B. R. Keeton Reoperations and survival after primary repair of congenital heart defects in children J. Thorac. Cardiovasc. Surg., August 1, 2003; 126(2): 511 - 520. [Abstract] [Full Text] [PDF]
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S. Weinstein, C. Cua, D. Chan, and J. T. Davis Outcome of symptomatic patients undergoing extracardiac Fontan conversion and cryoablation J. Thorac. Cardiovasc. Surg., August 1, 2003; 126(2): 529 - 536. [Abstract] [Full Text] [PDF]
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G. Baslaim, A. Hussain, A. Kouatli, and A. Jamjoom Bovine valved xenograft conduits in the extracardiac Fontan procedure J. Thorac. Cardiovasc. Surg., August 1, 2003; 126(2): 586 - 588. [Full Text] [PDF]
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S. P. McGuirk, D. S. Winlaw, S. M. Langley, O. F. Stumper, J. V. de Giovanni, J. G. Wright, W. J. Brawn, and D. J. Barron The impact of ventricular morphology on midterm outcome following completion total cavopulmonary connection Eur. J. Cardiothorac. Surg., July 1, 2003; 24(1): 37 - 46. [Abstract] [Full Text] [PDF]
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C. Varma, M. R. Warr, A. L. Hendler, N. S. Paul, G. D. Webb, and J. Therrien Prevalence of "silent" pulmonary emboli in adults after the Fontan operation J. Am. Coll. Cardiol., June 18, 2003; 41(12): 2252 - 2258. [Abstract] [Full Text] [PDF]
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T Rakow and C Bull Same patient, different advice: a study into why doctors vary Arch. Dis. Child., June 1, 2003; 88(6): 497 - 502. [Abstract] [Full Text] [PDF]
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G. Szabo, V. Buhmann, A. Graf, S. Melnitschuk, S. Bahrle, C. F. Vahl, and S. Hagl Ventricular energetics after the Fontan operation: Contractility-afterload mismatch J. Thorac. Cardiovasc. Surg., May 1, 2003; 125(5): 1061 - 1069. [Abstract] [Full Text] [PDF]
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M. R. Recto, W. Sobczyk, T. Yeh Jr, and E. H. Austin III Catheter closure of autologous pericardial extracardiac Fontan fenestration Ann. Thorac. Surg., February 1, 2003; 75(2): 587 - 590. [Abstract] [Full Text] [PDF]
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G Agnoletti, A Borghi, G Vignati, and G C Crupi Fontan conversion to total cavopulmonary connection and arrhythmia ablation: clinical and functional results Heart, February 1, 2003; 89(2): 193 - 198. [Abstract] [Full Text] [PDF]
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C. Stamm, I. Friehs, L. F. Duebener, D. Zurakowski, J. E. Mayer Jr, R. A. Jonas, and P. J. del Nido Improving results of the modified Fontan operation in patients with heterotaxy syndrome Ann. Thorac. Surg., December 1, 2002; 74(6): 1967 - 1978. [Abstract] [Full Text] [PDF]
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A. T. Yetman, J. Drummond-Webb, W. P. Fiser, M. L. Schmitz, M. Imamura, S. Ullah, R. J. Gunselman, C. W. Chipman, C. E. Johnson, and S. H. Van Devanter The extracardiac Fontan procedure without cardiopulmonary bypass: technique and intermediate-term results Ann. Thorac. Surg., October 1, 2002; 74(4): S1416 - 1421. [Abstract] [Full Text] [PDF]
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S. Fratz, J. Hess, M. Schwaiger, S. Martinoff, and H. C. Stern More Accurate Quantification of Pulmonary Blood Flow by Magnetic Resonance Imaging Than by Lung Perfusion Scintigraphy in Patients With Fontan Circulation Circulation, September 17, 2002; 106(12): 1510 - 1513. [Abstract] [Full Text] [PDF]
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M. Nanaumi, T. Asou, Y. Takeda, Z.-B. Lin, K. Ohara, and H. Yoshimura Total cavopulmonary connection via a thoracotomy Ann. Thorac. Surg., September 1, 2002; 74(3): 917 - 919. [Abstract] [Full Text] [PDF]
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A. Amodeo, M. Grigioni, G. Oppido, C. Daniele, G. D'Avenio, G. Pedrizzetti, S. Giannico, S. Filippelli, and R. M. Di Donato The beneficial vortex and best spatial arrangement in total extracardiac cavopulmonary connection J. Thorac. Cardiovasc. Surg., September 1, 2002; 124(3): 471 - 478. [Abstract] [Full Text] [PDF]
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R. G. Seipelt, A. Franke, J. F. Vazquez-Jimenez, P. Hanrath, G. von Bernuth, B. J. Messmer, and E. G. Muhler Thromboembolic complications after Fontan procedures: comparison of different therapeutic approaches Ann. Thorac. Surg., August 1, 2002; 74(2): 556 - 562. [Abstract] [Full Text] [PDF]
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B. Voss, F.-U. Sack, W. Saggau, S. Hagl, and R. Lange Atrial cardiomyoplasty in a Fontan circulation Eur. J. Cardiothorac. Surg., May 1, 2002; 21(5): 780 - 786. [Abstract] [Full Text] [PDF]
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R. Aeba, T. Katogi, K. Hashizume, Y. Iino, S. Kawada, and Y. Yuasa Individualized total cavopulmonary connection technique for patients with Asplenia syndrome Ann. Thorac. Surg., April 1, 2002; 73(4): 1274 - 1280. [Abstract] [Full Text] [PDF]
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R. F. Zhang, H. D. Gong, H. Y. Zhu, M. X. Hou, X. M. Li, J. Wang, H. C. Song, N. B. Zhang, and L. L. Tan Total Cavopulmonary Connection With Extraatrial Tunnel Asian Cardiovasc Thorac Ann, March 1, 2002; 10(1): 35 - 38. [Abstract] [Full Text] [PDF]
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Y. Yoshikawa, H. Ishibashi-Ueda, H. Uemura, Y. Kawahira, and T. Yagihara Pathologic findings in atrial musculature seven years after the intraatrial tunnel Fontan Ann. Thorac. Surg., February 1, 2002; 73(2): 663 - 664. [Abstract] [Full Text] [PDF]
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J. W. Gaynor, N. D. Bridges, M. I. Cohen, W. T. Mahle, W. M. DeCampli, J. M. Steven, S. C. Nicolson, and T. L. Spray Predictors of outcome after the Fontan operation: Is hypoplastic left heart syndrome still a risk factor? J. Thorac. Cardiovasc. Surg., February 1, 2002; 123(2): 237 - 245. [Abstract] [Full Text] [PDF]
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T. Suzuki, T. Murai, M. Sato, T. Ito, and T. Fukuda Arrhythmia after modified total cavopulmonary connection without use of prosthetic material Ann. Thorac. Surg., January 1, 2002; 73(1): 102 - 106. [Abstract] [Full Text] [PDF]
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J. M. Chu, Q. Y. Wu, and W. M. Wang Pulmonary Blood Distribution After Total Cavopulmonary Connection Asian Cardiovasc Thorac Ann, December 1, 2001; 9(4): 282 - 285. [Abstract] [Full Text] [PDF]
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A. Serraf, D. Piot, E. Belli, F. Lacour-Gayet, A. Touchot, R. Roussin, J. Zoghbi, J. Bruniaux, and C. Planche Biventricular repair of transposition of the great arteries and unbalanced ventricles J. Thorac. Cardiovasc. Surg., December 1, 2001; 122(6): 1199 - 1207. [Abstract] [Full Text] [PDF]
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Z. Amin, D. B. McElhinney, J. K. Strawn, J. D. Kugler, K. F. Duncan, V. M. Reddy, E. Petrossian, and F. L. Hanley Hemidiaphragmatic paralysis increases postoperative morbidity after a modified Fontan operation J. Thorac. Cardiovasc. Surg., November 1, 2001; 122(5): 856 - 862. [Abstract] [Full Text] [PDF]
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C. Mavroudis, C. L. Backer, B. J. Deal, C. Johnsrude, and J. Strasburger Total cavopulmonary conversion and maze procedure for patients with failure of the Fontan operation J. Thorac. Cardiovasc. Surg., November 1, 2001; 122(5): 863 - 871. [Abstract] [Full Text] [PDF]
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N. Yoshimura, M. Yamaguchi, Y. Oshima, S. Oka, Y. Ootaki, T. Tei, and S. Kido Risk factors influencing early and late mortality after total cavopulmonary connection Eur. J. Cardiothorac. Surg., September 1, 2001; 20(3): 598 - 602. [Abstract] [Full Text] [PDF]
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G R Veldtman, A Nishimoto, S Siu, M Freeman, P M Fredriksen, M A Gatzoulis, W G Williams, and G D Webb The Fontan procedure in adults Heart, September 1, 2001; 86(3): 330 - 335. [Abstract] [Full Text] [PDF]
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 T Rakow Differences in belief about likely outcomes account for differences in doctors' treatment preferences: but what accounts for the differences in belief? Qual. Saf. Health Care, September 1, 2001; 10(90001): i44 - 49. [Abstract] [Full Text] [PDF]
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H. Ohuchi, K. Yasuda, S. Hasegawa, A. Miyazaki, M. Takamuro, O. Yamada, Y. Ono, H. Uemura, T. Yagihara, and S. Echigo Influence of ventricular morphology on aerobic exercise capacity in patients after the Fontan operation J. Am. Coll. Cardiol., June 1, 2001; 37(7): 1967 - 1974. [Abstract] [Full Text] [PDF]
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Y. Tanoue, A. Sese, Y. Ueno, K. Joh, and T. Hijii Bidirectional Glenn Procedure Improves the Mechanical Efficiency of a Total Cavopulmonary Connection in High-Risk Fontan Candidates Circulation, May 1, 2001; 103(17): 2176 - 2180. [Abstract] [Full Text] [PDF]
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 J. A. Gaca, W. I. Douglas, and S. D. Barnes Anesthetic Implications of the Fontan Procedure for Single Ventricle Physiology Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2001; 5(1): 31 - 39. [Abstract] [PDF]
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D. D. Mair, F. J. Puga, and G. K. Danielson The Fontan procedure for tricuspid atresia: early and late results of a 25-year experience with 216 patients J. Am. Coll. Cardiol., March 1, 2001; 37(3): 933 - 939. [Abstract] [Full Text] [PDF]
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S. Sharma, A. E. Ensley, K. Hopkins, G. P. Chatzimavroudis, T. M. Healy, V. K.H. Tam, K. R. Kanter, and A. P. Yoganathan In vivo flow dynamics of the total cavopulmonary connection from three-dimensional multislice magnetic resonance imaging Ann. Thorac. Surg., March 1, 2001; 71(3): 889 - 898. [Abstract] [Full Text] [PDF]
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P M Fredriksen, J Therrien, G Veldtman, M A Warsi, P Liu, S Siu, W Williams, J Granton, and G Webb Lung function and aerobic capacity in adult patients following modified Fontan procedure Heart, March 1, 2001; 85(3): 295 - 299. [Abstract] [Full Text]
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C. Stamm, I. Friehs, J. E. Mayer Jr, D. Zurakowski, J. K. Triedman, A. M. Moran, E. P. Walsh, J. E. Lock, R. A. Jonas, and P. J. del Nido Long-term results of the lateral tunnel Fontan operation J. Thorac. Cardiovasc. Surg., January 1, 2001; 121(1): 0028 - 41. [Abstract] [Full Text] [PDF]
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