Extracardiac Cavopulmonary Connection Research Articles

Risk factors for the development of arrhythmias after the fontan surgery

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Fontan surgery or total cavopulmonary connection is a palliative procedure for complex congenital heart disease with univentricular physiology, without the possibility of biventricular surgical correction. This surgery has a high mortality rate (70%), with heart failure and arrhythmias being the main causes of death. Objective Identify the pre, intra and post-surgical factors that may predispose to arrhythmias in patients undergoing to Fontan surgery. Methods We conducted a retrospective review of the patients who underwent a total cavopulmonary connection from January 2003 to December 2018. We performed an analysis employing the Chi-square test to determine which variables were associated with the development of arrhythmias. Results During the mentioned period, 115 patients underwent to Fontan surgery, of which 51.3% were women, the average age at the time of surgery was 8 years. The most frequent diagnosis was tricuspid atresia in 44 patients (38.2%), followed by pulmonary atresia in 18 patients (15.7%) and double outlet right ventricle in 14 patients (12.2%). Regarding the type of the procedures performed, 93.9% (n = 108) were total extracardiac cavopulmonary connection and 6.1% (n = 7) were intracardiac. Also, 8.6% (n = 10) were taken to fenestration, the mean size of the fenestration was 7 mm (7 ± 3 mm) After Fontan surgery, there was a high incidence of arrhythmias which was 38% (n = 44). 22 patients (50%) presented them in the late postoperative period, being this, the most frequent time for the appearance of arrhythmias. We found that the intracardiac surgery presented an OR of 4.423 (95% CI 0.819 - 23.879, p> 0.05), being not statistically significant. Instead, the bidirectional cavopulmonary shunt previous to the Fontan surgery presented an OR of 0.255 (95% CI 0.081 - 0.806, p <0.05) and on the other hand the QRS duration > 120 ms was significantly associated with the appearance of arrythmias with an OR 2.99 (95% CI 1.2-4.2, p <0.05). Conclusions In patients undergoing to Fontan surgery, the previous bidirectional cavopulmonary bypass is a protective factor for the development of arrhythmias. And an QRS duration > 120 ms is a parameter that predicts the apparence of arrhythmias. Abstract Figure. QRS INTERVAL POST FONTAN SURGERY

Total cavopulmonary connection with a new restorative vascular graft: results at 2 years

BackgroundTo present a 2-year follow-up regarding safety and hemodynamic performance of a new restorative vascular graft used as extracardiac cavo-pulmonary connection in patients with univentricular congenital heart malformations.MethodsThe graft was implanted in five patients (aged 4–12 years) as extracardiac connection between the inferior vena cava and the pulmonary artery. The conduit consists of a bioabsorbable polymer-based implant able to generate endogenous tissue restoration leading to a fully functional neo-vessel while the polymer progressively absorbs. All patients have reached more than 24 months following surgery and underwent echocardiography and magnetic resonance imaging.ResultsAll patients are doing well at 24 months follow-up, with no graft-related serious adverse events. Transthoracic echocardiography demonstrated adequate function of the conduit in all patients while magnetic resonance imaging showed anatomical and functional stability of the restorative grafts.ConclusionsThe new restorative conduit has been successfully used for the second step of the Fontan procedure as extracardiac total cavopulmonary connection. The results are promising because they suggest that complete transformation of a bioabsorbable polymer and replacement through endogenous tissue may represent a major advantage in the treatment of congenital heart disease patients. Further monitoring will allow to evaluate the long-term behavior of this new graft, in terms of clinical and hemodynamic performance, thrombogenicity and ability to grow.

Mechanisms underlying abnormal cardiorespiratory response in Fontan patients

Low peak oxygen consumption (peak VO 2 ) is a strong predictor of mortality in adults with congenital heart diseases. In univentricular hearts, after Fontan procedure, peak VO 2 is known low at 59% of predicted value for the 50th percentile. But the mechanisms underlying this abnormal cardiorespiratory response to exercise are not well known. We aimed to determine which parameters can predict low peak VO 2 (< 59% of predicted value) in Fontan patients. Twenty-one patients (mean age 23 ± 8 years) underwent cardiopulmonary exercise testing (CPX) with arterial blood gas measurements. As expected, peak VO 2 was low (24.4 mL/kg/min). All patients, despite oxygen saturation, had resting shunt with PaO 2 + PaCO 2 <120 mmHg (mean 96 ±8 mmHg). Twelve patients had peak VO 2 < 59% of predicted value, which is considered < 50th percentile in Fontan population. In this group, resting oxygen saturation was lower (94.3 ± 1.8% vs. 96.7 ± 1.4%, P = 0.02), alveolar–arterial gradient was higher at rest (52 ± 9 mmHg vs. 44 ± 5 mmHg, P = 0.03) and at exercise (58 ± 10 mmHg vs. 50 ± 6 mmHg, P = 0.04). Secondly, these patients had lower exercise heart rate (122 ± 38 bpm vs. 169 ± 25 bpm, P = 0.002), lower chronotropic reserve (49 ± 31 bpm vs. 79 ± 17 bpm, P = 0.009) and had more often pacemakers (3 patients versus 0, P = 0.05). Finally, in this group with altered peak VO 2 , we found more Fontan procedures (or modified Fontan) than extracardiac total cavopulmonary connections (5 patients or 42% vs 1 or 11%, P = 0.03), patients were older (27.6 ± 7 years vs. 16.8 ± 6.4 years, P = 0.0009), and converted to extracardiac cavopulmonary connection later (at 21.1 ± 13.9 years old vs. 3.8 ± 2.4 years old, P = 0.002). Severe alteration of aerobic capacity evaluated by peak VO 2 measurement in Fontan patients is correlated to the importance of cyanosis, the limited capacity to raise heart rate at exercise and the type of surgery.

Invited Commentary

Invited Commentary

Fontan Pathway Growth: A Quantitative Evaluation of Lateral Tunnel and Extracardiac Cavopulmonary Connections Using Serial Cardiac Magnetic Resonance

Typically, a Fontan connection is constructed as either a lateral tunnel (LT) pathway or an extracardiac (EC) conduit. The LT is formed partially by atrial wall and is assumed to have growth potential, but the extent and nature of LT pathway growth have not been well characterized. A quantitative analysis was performed to evaluate this issue. Retrospective serial cardiac magnetic resonance data were obtained for 16 LT and 9 EC patients at 2 time points (mean time between studies, 4.2 ± 1.6 years). Patient-specific anatomies and flows were reconstructed. Geometric parameters of Fontan pathway vessels and the descending aorta were quantified, normalized to body surface area (BSA), and compared between time points and Fontan pathway types. Absolute LT pathway mean diameters increased over time for all but 2 patients; EC pathway size did not change (2.4 ± 2.2 mm vs 0.02 ± 2.1 mm, p < 0.05). Normalized LT and EC diameters decreased, while the size of the descending aorta increased proportionally to BSA. Growth of other cavopulmonary vessels varied. The patterns and extent of LT pathway growth were heterogeneous. Absolute flows for all vessels analyzed, except for the superior vena cava, proportionally to BSA. Fontan pathway vessel diameter changes over time were not proportional to somatic growth but increases in pathway flows were; LT pathway diameter changes were highly variable. These factors may impact Fontan pathway resistance and hemodynamic efficiency. These findings provide further understanding of the different characteristics of LT and EC Fontan connections and set the stage for further investigation.

281: Use of covered stents for closure of fenestration in extracardiac cavopulmonary connection: technical aspects and mid-term results

Closure of fenestration in a cavopulmonary connection (TCPC) is performed with devices used to close intracardiac or aorto-pulmonary connections. This study presents our data regarding the use of covered stents in patients with fenestrated TCPC. We retrospectively reviewed the data of all the patients receiving a covered stent to close a fenestration of TCPC between 2005 and 2012. 38 patients were included. Mean age and weight were respectively 7.6 years and 20 kg. Femoral access was mainly used (32) but also jugular access (5) and trans-hepatic access (1). A Cheatham Platinum Stent was used (34) but we also used Atrium V12 Stents (4). The balloon size was chosen according to the diameter of the conduit. We used BIB balloon (14) or simple balloon (Tyshak or Balt) (16) (balloon not reported (4)). Mean procedural and fluoroscopy times were respectively 42,5 +/ − 21 and 7,5±6,6 minutes. Mean central venous pressure rose from 10 to 12mmHg. Mean oxygen saturation increased from 90% to 96%. There was one anaphylactic shock at the end of the procedure and one air embolisation without hemodynamic compromise. Full occlusion was confirmed on angiogram in 36 patients. 2 cases required 2 stents to achieve full occlusion. There was one minimal residual shunt and one failure of the procedure with significant residual shunt in a patient with a conduit made of a Gore-Tex patch between the atrium and the pulmonary arteries. There were no embolic event, acute venous thrombosis or arrhythmias. Patients were treated with anti vitamin K for 6 months then aspirin. Mean follow-up is 49 months without thrombo-embolic complication or desaturation. Covered stent is an option to close fenestration in extracardiac TCPC. It is safe, easily achievable with low fluoroscopy time, very low risk of thrombo-embolic events or failure. The good results are sustainable. The main advantage of the technique is to avoid prosthetic device in the atrium

Time-resolved three-dimensional magnetic resonance velocity mapping of cardiovascular flow paths in volunteers and patients with Fontan circulation

To apply flow-sensitive magnetic resonance imaging for the evaluation of whole-heart flow characteristics in healthy volunteers and patients with Fontan circulation. Time-resolved three-dimensional magnetic resonance velocity mapping (spatial resolution = 2.5 × 2.8 × 2.8mm(3), temporal resolution = 38.4 ms) was acquired in normal controls and in four Fontan patients with extracardiac total cavopulmonary connection. Data analysis included flow connectivity mapping and flow quantification of arterial and venous blood flow. Haemodynamics in four patients with Fontan circulation were individually evaluated in the aorta, caval veins and left and right pulmonary arteries. In four controls, nine distinct flow features were consistently identified with good feature clarity (median = 2 in 80.6% of readings) and image quality (median = 2 in 75.0% of readings). In patients, a marked variability of flow from the caval veins towards the left and right pulmonary arteries (flow ratio = 1.7 ± 0.6, range 1.2-2.6 vs 1.1 ± 0.1 in controls) was found. Increased offset of the caval venous connection resulted in enhanced pulmonary flow asymmetry. Compared with controls, reduced pulsatility in pulmonary arteries (1.4 ± 0.6 vs 4.1 ± 0.6 in controls) and caval veins (1.2 ± 0.4 vs 2.8 ± 1.1 in controls) were observed. Peak flow was reduced in both superior (22 ± 14 mls(-1) vs 76 ± 7 mls(-1) in controls) and inferior vena cava (61 ± 28 mls(-1) vs 187 ± 42 mls(-1) in controls). This feasibility study demonstrated the potential of whole-heart three-dimensional magnetic resonance velocity mapping to reveal overt haemodynamic differences in surgically palliated congenital heart with similar extracardiac cavopulmonary connection geometry. Future studies are warranted to evaluate its diagnostic impact for improved evaluation of the pre- and postoperative status in the individual patient.

Avoiding cardiopulmonary bypass in extracardiac cavopulmonary connection: Does it really matter?

We examined the effect of avoiding cardiopulmonary bypass on the early outcome variables after fenestrated extracardiac total cavopulmonary connection. Between May 2001 and January 2009, 102 patients with univentricular heart physiology underwent fenestrated extracardiac total cavopulmonary connection. Patients were divided into one of 2 groups: the cardiopulmonary bypass (n = 48) group and the no cardiopulmonary bypass (n = 54) group. In both groups there were patients with primary and staged fenestrated extracardiac total cavopulmonary connection. Duration of mechanical ventilation, pleural effusion, hemodynamic status, incidence of arrhythmia, and mortality were compared between the 2 groups. Both groups were matched, except for more cases of tricuspid atresia in the no cardiopulmonary bypass group (P = .014) compared with other diagnostic morphologies and higher preoperative hemoglobin levels in the no cardiopulmonary bypass group (P = .01). Avoiding cardiopulmonary bypass did not reveal any significant effect on postoperative outcomes. A cardiopulmonary bypass time of more than 120 minutes caused not only a meaningful increase in the mean of mechanical ventilation duration (35 +/- 9.6 vs 13 +/- 2.1 hours, P = .026) but also increased the incidence of mechanical ventilation for more than 12 hours (P = .04). Bypass time of more than 120 minutes did not have influence on any other postoperative variables. Avoiding cardiopulmonary bypass in fenestrated extracardiac total cavopulmonary connection had no direct effect on the early outcome variables.

Staged Fontan's operation for unguarded tricuspid orifice with pulmonary atresia

We report a rare case of unguarded tricuspid orifice with pulmonary atresia, which is devoid of any guarding valvular tissue at tricuspid annulus. A left Blalock-Taussig shunt was constructed on the 17th day of life. At 4 years of age, a bidirectional Glenn's operation was performed for the further growth of the pulmonary bed and the volume reduction of the left ventricle. Finally, an extracardiac cavo-pulmonary connection was created using a ringed Gore-Tex graft at 6 years of age. Staged Fontan's strategy may contribute to a good surgical outcome for this highly lethal anomaly.

Results of 100 Consecutive Extracardiac Conduit Fontan Operations

Throughout the years, the experience with Fontan's operation has increased and has opened the way to a much wider application of this principle. A number of major risk factors have been identified and managed by several modifications of the original Fontan procedure. In the past 15 years, operative and postoperative risks have been controlled to a major extent by the application of intermediate surgical procedures. Modifications to the original technique have been designed to simplify surgery and better protect the myocardium by avoiding, as much as possible, prolonged ischemic time. In 1988, we developed a new form of total extracardiac right heart bypass by means of associating an extracardiac conduit placed between the inferior vena cava (IVC) and the pulmonary artery with a bidirectional cavopulmonary anastomosis (BCPA)--the so-called total extracardiac cavopulmonary connection (TECC). Between November 1997 and October 2003, 100 patients with complex cardiac anomalies underwent a modified Fontan operation by TECC. In 88 patients, the repair was staged by preliminary BCPA that was bilateral in 15 patients and associated with a modified Damus-Kaye-Stansel procedure to bypass a subaortic obstruction in 24 patients. Early (in hospital) deaths occurred in 6% of patients and the extracardiac conduit was taken down in 2 additional patients for a total early failure rate of 8%. The cause of death was myocardial failure in 5 patients. Pulmonary artery distortion or hypoplasia appeared to be the cause of death in 1 patient and the cause of failure in 1 patient. Atrioventricular valve regurgitation was the cause of failure in 1 patient. Follow-up to December 2003 was available in all surviving patients. There were no late deaths. At follow-up, 87 patients (89%) were in New York Heart Association (NYHA) functional class I, 4 in class II, and 3 in class III due to moderate to severe atrioventricular valve regurgitation. Use of the following guidelines can result in the achievement of orthoterminal repair with complete separation of pulmonary and systemic circulation, with negligible early mortality and a long-term NYHA class I: (1) Not all patients with univentricular heart (UVH) should undergo the extracardiac Fontan procedure; (2) in UVH with favorable streaming, a Q (p)/Q (s) ratio of approximately 1 to 1, and mild cyanosis, natural history might be preferable to surgical history; (3) any form of fenestration is contradictory to orthodox application of Fontan's principle. Children in whom a planned fenestration seems necessary because of suboptimal conditions should instead undergo a combination of BCPA and associated forward pulmonary blood flow; and (4) negligible mortality should be considered mandatory in UVH, normal pulmonary arteries, and absent cardiomegaly after appropriated and correct staging.

The patterns of flow in the total extracardiac cavopulmonary connection

more than 30 years ago, fontan and baudet proposed bypass of a dysfunctional right ventricle by connecting the pulmonary arteries directly to the right atrium, the so-called atriopulmonary anastomosis. since then, much experience has been accrued in the field of the functionally univentricular circulation. the proposed connections have been subjected to several modifications, aiming towards minimizing the losses of energy in the cavopulmonary system, and thereby improving the clinical outcomes. a remarkable improvement was achieved with the introduction of the concept of the total cavopulmonary connection, specifically the combination of a bi-directional glenn anastomosis with a tubular intracardiac extension from the inferior caval venous to the pulmonary arteries. this design was shown to avoid the dissipation of energy associated with the swirling patterns seen in the traditional atrio-pulmonary anastomosis.

Total extracardiac cavopulmonary connection: an alternative technique of fenestration

Fenestrating an extracardiac conduit used for total cavopulmonary connection normally requires an additional incision on the right-sided atrium and is time consuming. Herein we describe an alternative technique that may be used to facilitate this process, which consists of creating the fenestration by using part of the atrial incision resulting from the disconnection of the inferior vena cava from the right atrium. The advantages of this technique are avoidance of an extra incision and suture line on the atrium, and the ease of construction. This may be especially useful in patients with heterotaxy syndromes with mesocardia or dextrocardia, in whom the atrial mass is displaced posteriorly and can be difficult to reach. Closure of the fenestration can be easily performed at a later stage in the cardiac catheterization laboratory by using a septal occluding device.

Severe Cyanosis After Total Cavopulmonary Connection, Corrected by Surgical Ligation of the Suprahepatic Veins

We describe a patient with a diagnosis of heterotaxia and independent drainage of the suprahepatic veins into the venous atrium who underwent total extracardiac cavopulmonary connection in which hepatic vein drainage remained directly into the atrium. In the immediate postoperative period she showed increasing cyanosis that suggested substantial right-to-left shunt. Surgical ligation of the suprahepatic veins resolved the complication effectively without signs of hepatic congestion or portal hypertension.

What was the impact of the introduction of extracardiac completion for a single center performing total cavopulmonary connections?

Creation of an extracardiac cavopulmonary connection has been proposed as a superior alternative to the lateral intracardiac tunnel for the completion of total cavopulmonary connection. We made a retrospective review of our experience with 125 patients undergoing a total cavopulmonary connection between June 1994 and January 2003. Our experience with the extracardiac connection for completion began in 1999. Since 1994, we have constructed an intracardiac tunnel in 50 patients, and an extracardiac connection in 75. Of the total number, 83 had undergone an earlier partial cavopulmonary connection. Additional intracardiac procedures were performed in 43 patients at time of completion, in 25 of those undergoing extracardiac completion, and in 18 of the patients having an intracardiac procedure. The mean size of the tube used for completion was 19 mm. The mean cross-clamp time for placement of the intracardiac tunnel was 77 min, with a median of 80.5 min, and a mean cardiopulmonary bypass time of 139 min, with a median of 131 min. For construction of the extracardiac connection, a mean cross-clamp time in 24 of the 75 patients was 54 min, with a median of 54 min. Mean cardiopulmonary bypass time for all the patients with an extracardiac connection was 100 min, with a median of 88 min. Reoperations were needed in 10 patients, 6 having intracardiac and 4 extracardiac procedures. Of these, 5 were early and 5 late, including one take down. None of the patients died after these interventions. Taken overall, 8 patients died, with 5 early deaths. In the multivariable analysis, cardiopulmonary bypass time of more than 120 min, atrioventricular valvar replacement, and banding of the pulmonary trunk prior to the total cavopulmonary connection, all reached statistical significance for early death, whereas only heterotaxy syndrome remained as the sole risk factor for late death. There was no significant difference in survival between the modifications used. Whereas we could not identify any clinical superiority for the extracardiac approach in the short-term, the concept of extracardiac completion has helped to simplify the overall procedure. Longer follow-up will be required to elucidate any potential advantages.

Bovine valved xenograft conduits in the extracardiac Fontan procedure

Total cavopulmonary connection has been proposed as a rational alternative to atriopulmonary connection for complex Fontan operations. de Leval and colleagues proposed the concept of direct cavopulmonary connection as a way to minimize kinetic energy loss in the Fontan circuit. Total cavopulmonary anastomosis with the extracardiac conduit technique has gained favor because it streamlines the venous flow pattern and reduces the incidence of atrial arrhythmias. There are a number of potential advantages of the extracardiac conduit approach over other modifications of the Fontan procedure, including the improved hydrodynamics in the cavopulmonary connection. Conduits of different material have been used for the extracardiac Fontan procedure, examples of these conduits are the Dacron tube, the polytetrafluoroethylene tube (Gore-Tex; W. L. Gore & Associates, Inc, Flagstaff, Ariz), the homograft, and the pericardial tube, and each one has advantages and disadvantages. Bovine jugular vein xenograft (Medtronic’s Contegra, Medtronic, Inc, Minneapolis, Minn) has been used successfully to reconstruct the right ventricular outflow tract in patients with congenital heart disease, with promising early results. The Contegra conduit is a biologic valved conduit consisting of a glutaraldehyde-preserved heterologous bovine jugular vein with a trileaflet venous valve. The advantages of using the Contegra xenograft are easy availability, different size options, and the presence of a valve in the conduit. In this report we present potential advantages of using a xenograft valved conduit to construct the extracardiac Fontan connection between the inferior vena cava (IVC) and the pulmonary artery (PA).

The beneficial vortex and best spatial arrangement in total extracardiac cavopulmonary connection

Objective: Total extracardiac cavopulmonary connection is an established procedure, but the best spatial arrangement remains controversial. On the basis of our clinical experience with total extracardiac cavopulmonary connection, we performed quantitative and qualitative flow analysis on total extracardiac cavopulmonary connection models simulating the two most frequent arrangements applied to our patients to determine the most favorable hydrodynamic pattern. Methods: We selected two main groups among 110 patients who underwent total extracardiac cavopulmonary connection, those with left-sided inferior vena cava anastomosis (type 1) and those with facing superior and inferior vena cava anastomoses (type 2). Blown-glass total extracardiac cavopulmonary connection phantom models were constructed on the basis of nuclear magnetic resonance and angiographic images. Flow measurements were performed with a Nd:YAG Q-switched laser and a particle imaging velocimetry system. A power dissipation study and a finite-element numeric simulation were also carried out. Results: When applying superior and inferior vena caval flow proportions of total systemic venous return of 40% and 60%, respectively, a vortex was visualized in the type 1 phantom that rotated counterclockwise at the junction of the caval streams. This apparent vortex was not a true vortex; rather, it represented a weakly dissipative recirculating zone modulating the flow distribution into the pulmonary arteries. The power dissipation and finite-element numeric stimulation confirmed the beneficial nature of the apparent vortex and a more energy-saving pattern in the type 1 phantom than in the type 2 phantom. Conclusion: Total extracardiac cavopulmonary connection with left-sided diversion of the inferior vena caval conduit anastomosis is characterized by a central vortex that regulates the caval flow partitioning and provides a more favorable energy-saving pattern than is seen with the total extracardiac cavopulmonary connection with directly opposed cavopulmonary anastomoses.J Thorac Cardiovasc Surg 2002;124:471-8

Revision of previous Fontan connections to total extracardiac cavopulmonary anastomosis: A multicenter experience

Background: Conversion to total extracardiac cavopulmonary anastomosis is an option for managing patients with dysfunction of a prior Fontan connection. Methods: Thirty-one patients (19.9 ± 8.8 years) underwent revision of a previous Fontan connection to total extracardiac cavopulmonary anastomosis at four institutions. Complications of the previous Fontan connection included atrial tachyarrhythmias (n = 20), progressive heart failure (n = 17), Fontan pathway obstruction (n = 10), effusions (n = 10), pulmonary venous obstruction by an enlarged right atrium (n = 6), protein-losing enteropathy (n = 3), right atrial thrombus (n = 2), subaortic stenosis (n = 1), atrioventricular valve regurgitation (n = 3), and Fontan baffle leak (n = 5). Conversion to an extracardiac cavopulmonary connection was performed with a nonvalved conduit from the inferior vena cava to the right pulmonary artery, with additional procedures as necessary. Results: There have been 3 deaths. Two patients died in the perioperative period of heart failure and massive effusions. The third patient died suddenly 8 months after the operation. All surviving patients were in New York Heart Association class I (n = 20) or II (n = 7), except for 1 patient who underwent heart transplantation. Early postoperative arrhythmias occurred in 10 patients: 4 required pacemakers, and medical therapy was sufficient in 6. In 15 patients, pre-revision arrhythmias were improved. Effusions resolved in all but 1 of the patients in whom they were present before revision. The condition of 2 patients with protein-losing enteropathy improved within 30 days. Conclusions: Conversion of a failing Fontan connection to extracardiac cavopulmonary connection can be achieved with low morbidity and mortality. Optimally, revision should be undertaken early in symptomatic patients before irreversible ventricular failure ensues. (J Thorac Cardiovasc Surg 2000;119:340-6)

Modified Fontan without use of cardiopulmonary bypass

Background. Direct cavopulmonary connection using an extracardiac conduit has a number of theoretical advantages in the staged management of children with single ventricular congenital heart defects. With appropriate planning, completion Fontan using an extracardiac connection may be accomplished without the use of cardiopulmonary bypass.Methods. From January 1995 to October 1997, 32 consecutive patients underwent completion Fontan using an extracardiac cavopulmonary connection. Twenty-one of these patients had completion Fontan without the use of cardiopulmonary bypass (No CPB group). Their postoperative outcome was retrospectively compared with a second group of 11 patients who underwent completion Fontan with an extracardiac conduit with the use of cardiopulmonary bypass.Results. There was no operative or hospital mortality in either group. Early postoperative hemodynamics appear to be significantly improved in the No CPB group. Transfusion of cryoprecipitate and platelets was significantly less in the group without the use of cardiopulmonary bypass (p = 0.026, p < 0.001, respectively). Review of the most recent 12 patients also demonstrated a substantially shorter extubation time and intensive care unit stay. The length of hospital stay was significantly shorter (p = 0.036).Conclusions. Completion Fontan without the use of cardiopulmonary bypass results in improved immediate postoperative hemodynamics, and decreased use of blood and blood products. The most recent group appears to demonstrate a more rapid recovery time and shorter hospital stay (p = 0.036).

Late Results of Extracardiac Fontan Repair

The Fontan procedure by means of an extracardiac conduit was initially proposed for patients presenting with anomalies of intra-atrial anatomy. We extended this technique to all patients with functional anatomic single ventricle. Between 1988 and 1998, 206 patients with complex cardiacanomalies underwent a total extracardiac cavopuolmonary connection. In 202 patients we used a conduit, in 4 patients we performed an IVC to pulmonary artery direct anastomosis. Ten patients underwent Conversion of a filing atriopulmonary Fontan procedure to a total extracardiac cavopulmonary connection. Early deaths occurred in 10% of patients and the extracardiac conduit was taken down in 3 additional patients. The cause of death was myocardial failure in 13 patients. Pulmonary distortion or hypoplasia in 6. No deaths have occurred in our last 45 patients. We observed no cases of conduit obstruction and thrombosis. Arrthymias were present in 16 patients. Ten patients underwent conversion of a formed modified Fontan. There were no immediate postoperative deaths. These results demonstrate that the total extracardiac cavopulmonary connection provide good early and mildterm results and is the technique of choice for a Fontan type repair. Copyright 1999 by W.B. Saunders Company

Extracardiac cavopulmonary connection of fontan procedure with autologous pedicled pericardium without cardiopulmonary bypass

cision. This tremor elimination and computer motion scaling overcome perhaps the most significant limitation of conventional endoscopic instruments. Although further chronic studies are necessary to fully validate the clinical utility of this robotic instrumentation, the current study provides encouraging preliminary results. Robotic assistance in the microsurgical environment may allow for the development of completely endoscopic CABG.