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J Thorac Cardiovasc Surg 2006;131:247-249
© 2006 The American Association for Thoracic Surgery
Brief Communication |
a Division of Cardiology, Children's Hospital of Michigan, Detroit, Mich
b Department of Pediatrics, the Division of Pediatric Cardiovascular Surgery, Children's Hospital of Michigan, Detroit, Mich
c Department of Pediatrics, Children's Hospital of Michigan, Detroit, Mich
Received for publication August 1, 2005; revisions received September 2, 2005; accepted for publication September 8, 2005. * Address for reprints: Swati Garekar, MD, Pediatric Cardiology, Children's Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI 48201 (Email: swatigar{at}gmail.com).
The fenestrated Fontan (FF) procedure is associated with better hemodynamics postoperatively than the modified Fontan procedure without a fenestration.
1,2
Although a fenestration improves cardiac output, there is a cost of right-to-left shunting, cyanosis, and the subsequent risk of thromboembolism.
Our goal was to evaluate our experience with FF procedures. Specifically, we sought (1) to assess the outcomes of closed fenestrations, (2) to determine the rate of spontaneously closed fenestrations, and (3), among patients with patent fenestrations, to determine whether a clinical or laboratory variable could be used to predict their outcomes.
After institutional review board approval, 23 FF procedures with no other source of significant right-to-left shunt were identified. The cardiac lesion in the majority of patients (16/23 [70%]) was hypoplastic left heart syndrome.
Pre-Fontan Catheterization Hemodynamics
The average mean pulmonary artery pressure was 11 ± 2.8 mm Hg. The mean pulmonary vascular resistance (PVR) was 2.3 ± 1.5 indexed Wood units. The mean systemic ventricular end-diastolic pressure was 7.8 ± 2.6 mm Hg.
Surgical Results
The mean age at the time of the operation was 24.7 ± 9 months. Twenty-two of the 23 patients received the lateral tunnel Fontan procedure, and the remaining patient received an extracardiac conduit. The fenestration was a single 4-mm punch in 14 patients. Additional procedures performed along with the Fontan procedure were pulmonary artery patch angioplasty (n = 4) and atrioventricular (AV) valvuloplasty (n = 3). The mean hospital stay after surgical intervention was 13.4 ± 7.4 days. The median follow-up period after the Fontan procedure was 16 months (range, 2-134 months).
Spontaneously Closed Fenestrations
There was spontaneous closure of the fenestration in 5 (22%) patients (Table 1). One of these did not tolerate this closure and has had a transplantation. The other 4 patients are clinically stable. The size of the fenestrations varied from 2 punches of 2.5 mm (n = 2), a single 4-mm punch (n = 2), and a single 5-mm punch (n = 1). There was no correlation between the size of fenestration created and the likelihood of closure.
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Data on catheterization laboratory closure of fenestrations are shown in Table 1. Three patients were referred to the catheterization laboratory for device closure of the fenestration, of which 2 underwent device placement after favorable hemodynamics were demonstrated on test occlusion of the fenestration. The patients were referred for device closure because of desaturation in 2 patients and persistent headaches in the third. There were no infarcts seen on brain imaging in the patient with headaches, and the headaches have persisted after device closure.
Patent Fenestrations
There were 20 patients with complete data, of whom 14 had patent fenestrations. The cohort was divided into 3 groups on the basis of fenestration status on the most recent echocardiogram: group 1, closed fenestration; group 2, patent fenestration and low resting saturation (<94%); and group 3, patent fenestration but normal resting saturation (
94%).
Comparison Between Groups
Data on comparison between groups are shown in Table 2. There was no difference between the groups with respect to age at the time of the Fontan procedure, the pre-Fontan mean pulmonary artery pressure, or the systemic ventricular end-diastolic pressure. The preoperative PVR was significantly lower in group 3 (P < .05). No group 3 patients had significant AV valve regurgitation or ventricular dysfunction at the most recent clinic visit. Patients in groups 1 and 2 had a higher incidence of moderate or severe decrease of ventricular function, New York Heart Association class 2 or greater, and hepatomegaly at the most recent clinic visit when compared with group 3.
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Historically, the interval between the FF procedure and device closure of the fenestration has ranged from less than a week to 3 years postoperatively.
3,4
The trend has been to wait at least 6 months before contemplating closure. Waiting for a longer period exposes the patient to potential adverse effects of cyanosis and the risk of thromboembolism. No patient in this study had clinically detectable thromboembolism. Our data show that spontaneous closure can occur as early as 2 months and up to 83 months after the operation. Closure of fenestration was not necessarily associated with a good outcome.
There are some proponents of the view that fenestrations should not be closed because they preserve cardiac output and prevent central venous pressure from increasing. This seems like a good option for the patients in our study with patent fenestrations whose resting peripheral arterial saturations were normal. The patients in this group had no significant AV leakage or ventricular dysfunction and were doing well clinically at the most recent clinic visit. These patients might have done well in part because of a lower pre-Fontan PVR. Whether patients with patent fenestrations but low resting saturations would benefit from device closure requires further study; however, those within this group who have preserved ventricular function and minimal AV regurgitation might be good candidates for this procedure.
References
This article has been cited by other articles:
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  J. W. Salvin, M. A. Scheurer, P. C. Laussen, J. E. Mayer Jr, P. J. del Nido, F. A. Pigula, E. A. Bacha, and R. R. Thiagarajan Factors Associated With Prolonged Recovery After the Fontan Operation Circulation, September 30, 2008; 118(14_suppl_1): S171 - S176. [Abstract] [Full Text] [PDF]
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