PII: S0003-4975(99)01464-2

Abstract

This is an interesting report of a small group of highly selected patients in whom the right ventricle was incorporated in a Fontan type circuit. With advances in surgery of the Fontan type in recent years, eg the total cavopulmonary connection (TCPC) and extra cardiac conduit, there is probably no reason for doing this type of operation even if the patient had a good ventricle. In the authors experience, the outcome was better for those who had a Bjork type operation with a direct right atrium (RA) to right ventricle (RV) connection, but the RV was not really pumping. If the RV is big enough to contribute to the circulation properly, it is necessary to have a valve in the conduit between the RA and RV, otherwise the RV will be pumping blood back into the right atrium and this would have a bad effect. Certainly, if a valved conduit is used, there is good evidence that the right ventricle can actually pump efficiently with good forward flow. However, the main problem, as illustrated in this paper, is that the conduits get compressed behind the sternum and then they calcify and obstruct. These can be replaced, but the big question is should another conduit be put in to try and preserve a good right ventricle, or should all patients be converted to a TCPC type circulation. The probable answer to this question is that the right ventricle should only be preserved if it is really a good size, functioning well, and the conduit being replaced can be protected from compression by the sternum. Probably all of the patients should be converted to a TCPC type anatomy. A question does remain, though about what should be done with the right ventricle that is likely to clot off and, if left in the circulation thrombi, could be problematic. Certainly, all patients should be on Warfarin.