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J Thorac Cardiovasc Surg 2008;136:1393
© 2008 The American Association for Thoracic Surgery

Letter to the Editor

Contegra and extracardiac Fontan

Division of Cardiothoracic Surgery, Department of Cardiovascular Diseases, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia

To the Editor:

We read with the greatest interest the article entitled "Feasibility of the Extracardiac Conduit Fontan Procedure in Patients Weighing Less than 10 Kilograms."¹ After congratulating the authors for their excellent work, we have a few comments.

As a Fontan Conduit, they used polytetrafluoroethylene (Gore-Tex; WL Gore & Associates Inc, Flagstaff, Ariz) (14–20 mm in diameter) King Faisal Specialist Hospital and Research Center in Jeddah, used Contegra valved conduits in 4 patients for inferior vena cava–right pulmonary artery connection (Fontan). They speculated that an additional benefit of using the Contegra xenograft could be that it provides a competent valve in the Fontan circulation, which might help by reducing the reversal of flow and maintaining better forward flow into the pulmonary circulation. The concern was whether the valve, in a nonpulsatile, passive Fontan circulation, would facilitate smooth antegrade flow into the pulmonary circulation or act as a source of resistance to the flow. The findings that none of their patients had hepatomegaly or ascites on physical examination and that the postoperative echocardiograms showed excellent antegrade flow in the inferior vena cava, which also was not dilated, and minimal flow reversal in the hepatic veins support the facilitation of smooth forward flow. They presented a new option for constructing an extracardiac Fontan connection with the Contegra xenograft that has not been previously published. Their early echocardiographic results supported the idea of minimizing the reversal of infradiaphragmatic venous flow, decreasing hepatic congestion, and possibly reducing the development of ascites.² They do have a way of assessing the conduit size by using Rowlatt and colleagues' chart.³

The authors routinely administered 5 mg/kg ticlopidine as antiplatelet therapy. Warfarin was not used even though they had a patient with arteriovenous valve replacement. How did they control the thrombogenic potential here?

Measurement of the lower lobe index is an important adjunct to evaluate candidates for the Fontan operation. The predictive value of the Nakata index is less informative than the lower lobe index, which was introduced to optimize the preoperative selection of Fontan candidates. Lower lobe index may be more predictive to evaluate the adequacy of the pulmonary vascular tree, given that central pulmonary arteries used to calculate the Nakata index can be enlarged before or during the Fontan operation.⁴

References

1. Ikai A, Fujimoto Y, Hirose K, Ota N, Tosaka Y, Nakata T, et al. Feasibility of the extracardiac conduit Fontan procedure in patients weighing less than 10 kilograms. J Thorac Cardiovasc Surg 2008;135:1145-1152.[Abstract/Free Full Text]
   
2. Baslaim G, Hussain A, Kouatli A, Jamjoom A. Bovine valved xenograft conduits in the extracardiac Fontan procedure. J Thorac Cardiovasc Surg 2003;126:586-588.[Free Full Text]
   
3. Rowlatt JF, Rimaldi JMA, Lev M. The quantitative anatomy of the normal child's heart. Pediatr Clin North Am 1963;10:499-588.
   
4. Ovroutski S, Alexi-Meskishvili V. Does the Nakata index predict outcome after Fontan operation?. Eur J Cardiothorac Surg 2008;33:951.[Medline]
   

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				P. Schoof and T. Waterbolk Contegra and extracardiac Fontan J. Thorac. Cardiovasc. Surg., July 1, 2009; 138(1): 258 - 259. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Sameh Ibrahim Sersar Ahmed A. Jamjoom Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sersar, S. I. Articles by Jamjoom, A. A. Search for Related Content PubMed Articles by Sersar, S. I. Articles by Jamjoom, A. A. Related Collections Congenital - acyanotic Congenital - cyanotic Related Article