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J Thorac Cardiovasc Surg 1995;110:1766-1768
© 1995 Mosby, Inc.

BRIEF COMMUNICATIONS

EXTRACARDIAC MODIFICATION OF THE FONTAN OPERATION WITHOUT USE OF PROSTHETIC MATERIAL

San Francisco, Calif.

From the Division of Cardiothoracic Surgery, UCSF, San Francisco, Calif.

Accepted for publication Jan. 3, 1995. Since 1992, we have routinely performed the modified Fontan procedure with the use of an extracardiac conduit (nonvalved aortic homograft or polytetrafluoroethylene). ^1-3 * In this article we describe a technique of extracardiac Fontan operation without use of prosthetic material that is applicable in hearts with L-malposition or L-transposition of the aorta.

Case presentation

An 11-year-old boy with situs solitus, double-outlet right ventricle, L-malposition of the aorta, noncommitted ventricular septal defect, severe infundibular and valvular pulmonary stenosis with adequately developed main and branch pulmonary arteries, and bilateral superior venae cavae (SVCs) had been observed since birth. A central aortopulmonary shunt and a left modified Blalock-Taussig shunt had been performed in the past at another hospital. The remote position of the aortic valve relative to the ventricular septal defect and the location of the tricuspid valve precluded a biventricular repair.

A median sternotomy was performed. The main pulmonary artery and its branches and both aortopulmonary shunts were dissected and completely mobilized. After aortic and bicaval cannulation (with the cannula in the inferior vena cava [IVC] placed as low as possible), cardiopulmonary bypass was instituted, snares around the SVCs and IVC were tightened, and the aortopulmonary shunts were ligated and transected. The right SVC was transected at its entrance into the right atrium and the atrium was oversewn. The left SVC was transected in a similar fashion. The right atrium was clamped at its base just proximal to its junction with the IVC, avoiding the coronary sinus, and transected below the clamp, thereby leaving a beveled cuff of atrial tissue attached to the IVC (Fig. 1). The right atrium was oversewn. With the aorta temporarily crossclamped, the main pulmonary artery was transected at the base of the pulmonary valve to preserve as much length of the main pulmonary artery as possible. The pulmonary anulus was oversewn. Subsequently, the main pulmonary artery was anastomosed end-to-end to the IVC with 6-0 polyglyconate suture (Maxon, Davis & Geck, Inc., Danbury, Conn.). The right and left SVCs were anastomosed to their respective branch pulmonary arteries in an end-to-side fashion with Maxon sutures (Fig. 2).

View larger version (107K): [in this window] [in a new window]   Fig. 1. Technique of extracardiac Fontan operation with exclusive use of native tissue in heart with double-outlet right ventricle and L-malposition of the aorta. After complete mobilization of the main and branch pulmonary arteries, the IVC and SVCs are transected at their entrance sites into the right atrium, so that a cuff of atrial tissue is left attached to the IVC (dotted lines). The right atrium is oversewn. The main pulmonary artery is transected just distal to the anulus (dotted line). Transection of the right SVC at the cavoatrial junction allows the main pulmonary artery to easily reach the IVC.

View larger version (131K): [in this window] [in a new window]   Fig. 2. The main pulmonary artery is anastomosed to the IVC. The right and left SVCs are anastomosed in an end-to-side fashion to their respective pulmonary arteries. The pulmonary anulus is oversewn.

Discussion

Over the past decade, improved patient selection and staged management of patients with univentricular physiology has led to better candidates for the modified Fontan operation by drastic reduction of the deleterious effects of long-term ventricular volume overload, repeated palliative procedures, and chronic hypoxemia. ^4-6 Important remaining challenges in the treatment of the underlying cardiac malformations involve reduction of perioperative and long-term morbidity after the Fontan procedure. Since 1992, we have performed 50 Fontan operations with the use of an extracardiac conduit. We speculate that construction of an extracardiac conduit may have several advantages as compared with an intraatrial lateral tunnel repair or right atrium–pulmonary artery anastomosis. First, the extracardiac technique allows the entire Fontan operation to be performed as a "closed" procedure with a beating heart on cardiopulmonary bypass, without the need for aortic crossclamping (no-touch technique), which avoids myocardial ischemia. Second, this technique may reduce the prevalence of conduit irregularity because of the more uniform caliber and circular geometry of the extracardiac tunnel. Therefore, the occurrence of turbulence, an unfavorable property with regard to Fontan physiology, ⁷ may be reduced. Third, reduction in size and wall stress of the right atrium, absence of extensive atrial suture lines (as present in the intraatrial lateral tunnel repair, in particular when a flap of atrial free wall is used ^8,9 ), and avoidance of damage to the sinoatrial node at the time of conversion from the bidirectional cavopulmonary anastomosis to the Fontan circulation may reduce the prevalence and progression of both early and late atrial arrhythmias (with an incidence as high as 20% after a conventional Fontan repair ⁶ ), atrial thrombus formation, and atrially induced pulmonary venous obstruction. In high-risk patients such as those with increased pulmonary vascular resistance, pulmonary hypertension, and impaired ventricular function, an adjustable fenestration between the extracardiac conduit and the common atrium may be added. ¹⁰

In most cases, prosthetic material in one form or another is necessary when an extracardiac tunnel is constructed to bridge the gap between the IVC and the corresponding branch pulmonary artery. Construction of an extracardiac conduit without use of prosthetic material may be feasible in hearts with situs solitus, levocardia, and L-transposition or L-malposition of the aorta (or, alternatively, situs inversus, dextrocardia, and D-transposition or D-malposition of the aorta) in the presence of an adequately developed main pulmonary artery, as in the case presented here. This modification has all of the advantages of exclusive use of native tissue, including growth potential at pediatric age, as well as reduced risk of thrombus formation (and therefore avoidance of need for anticoagulation), elimination of peel formation, lower infection rate, and reduced cost. Long-term follow-up of the results of this technique will provide further information regarding all these aspects.

Footnotes

J THORAC CARDIOVASC SURG 1995;110:1766-8

*Gore-Tex graft, registered trademark of W.L. Gore & Associates, Inc., Newark, Del.

References

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2. Nawa S, Teramoto S. New extension of the Fontan principle: inferior vena cava–pulmonary artery bridge operation. Thorax 1988;43:1022-3.[Abstract]
   
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5. Caspi J, Coles JG, Rabinovich M, et al. Morphological findings contributing to a failed Fontan procedure: twelve-year experience. Circulation 1990;82(Suppl):IV177-82.
   
6. Driscoll DJ, Offord KP, Feldt RH, Schaff HV, Puga FJ, Danielson GK. Five- to fifteen-year follow-up after Fontan operation. Circulation 1992;85:469-96.[Abstract/Free Full Text]
   
7. de Leval M, Kilner P, Gewillig M, Bull C, McGoon DC. Total cavopulmonary connection: a logical alternative to atriopulmonary connection for complex Fontan operations—experimental studies and early clinical experience. J THORAC CARDIOVASC SURG 1988;96:682-95.[Abstract]
   
8. van de Wal HJCM, Tanke RF, Roef MJ. The modified Senning operation for cavopulmonary connection with autologous tissue. J THORAC CARDIOVASC SURG 1994;108:377-80.[Abstract/Free Full Text]
   
9. Sarioglu T, Paker T, Türkoglu H, et al. The modified Fontan operation in hearts with atrioventricular valve atresia or common atrioventricular valve-neoseptation of the atriums using a right atrial flap. Cardiol Young 1994;4:353-7.
   
10. Black MD, van Son JAM, Haas GS. Extracardiac Fontan with adjustable communication. Ann Thorac Surg [In press].
    

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This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jacques A. M. van Son Frank L. Hanley Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by van Son, J. A. M. Articles by Hanley, F. L. Search for Related Content PubMed PubMed Citation Articles by van Son, J. A. M. Articles by Hanley, F. L.