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J Thorac Cardiovasc Surg 2004;127:608-609
© 2004 The American Association for Thoracic Surgery

Letter to the editor

Modified Fontan procedure in adults

Manoj Purohit

SPR, Paediatric Cardiac Surgery Alder hey Hospital Liverpool, United Kingdom

To the Editor:

At the outset I must congratulate and thank the authors of this article for this landmark work on the Fontan procedure in an adult population.1 This is going to be a benchmark for adult Fontan procedure in years to come.

In the Western hemisphere the Fontan surgery is done in children; adult patients undergoing this procedure are exceptions, not the rule. But in developing countries adult patients for univentricular palliation, with or without prior surgical palliation, are quite common.2 As the authors have addressed, the primary issue for these patients is suitability for surgery. I am unclear on a few points in the article, however, and have some questions for the authors.

This landmark work began just after introduction of the Fontan principle. Is this why initial modifications were done in a majority of patients? Or is there another reason? Do you continue to do these modifications today? If so, for what indications and why? The issue of superiority of 1 modification over others in long-term results is far from resolved. For budding cardiac surgeons like me, which type of modification do you recommend for hemodynamically adequate adult patients? In other words, what should govern my choice of modification in different sets of patients?

The fenestrated Fontan modification has widened the horizon of univentricular repair. You have elaborately described your point. Do you feel in spite of anticoagulation the incidence of thromboembolic and other side effects or complications outweighs the benefit of fenestration in decreasing the morbidity of procedure, which has been vigorously tested? Does the age of the patients also affect the decision to fenestrate? If yes, in what way?2,3

What is your policy regarding 1-stage or 2-stage procedure? For example, do you perform superior cavopulmonary first and then complete the Fontan as a separate procedure, especially for patients without palliation or with systemic to pulmonary artery shunts or pulmonary artery banding? Is the principle of gradual volume unloading of the ventricle different in adults than children?

Once again, I thank the authors for this outstanding article.


   References
Top
 References
 

  1. Burkhart HM, Dearani JA. The modified Fontan procedure: early and late results in 132 adult patients. J Thorac Cardiovasc Surg. 2003;125:1252–1259[Abstract/Free Full Text]
  2. Airan B, Sharma R, Choudhary S, Mohanty SR. Univentricular repair: is routine fenestration justified? Ann Thorac Surg. 2000;69:1900–1906[Abstract/Free Full Text]
  3. Lemler MS, Scott WA, Steven R. Fenestration improve clinical outcome of Fontan procedure: a prospective randomized study. Circulation. 105:207-12



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