Asian Cardiovasc Thorac Ann 2000;8:264-265
© 2000 Asia Publishing EXchange Pte Ltd
Extracardiac Fontan/Kawashima Procedure Without Cardiopulmonary Bypass
Rajiv Kumar, MCh,
Susan Samuel, MD,
K Srinivas Sai, MCh,
Mahesh Vakamudi, MD,
Richard Saldanha, MCh,
Komarishi Rajagopalan Balakrishnan, MCh
Department of Cardiothoracic Surgery
Sri Ramachandra Hospital
Chennai, India
|
|
For reprint information contact: Rajiv Kumar, MCh Tel: 91 44 482 9033 Fax: 91 44 476 6990 email: cvskrb{at}giasmd01.vsnl.net.in Department of Cardiothoracic Surgery, Sri Ramachandra Hospital, 1 Ramachandra Nagar, Porur, Chennai 600116, India.
|
 |
Abstract
|
|---|
Two patients with univentricular physiology underwent successful surgical palliation without the use of cardiopulmonary bypass. A 19-year-old girl had an extracardiac Fontan operation and a 4-year-old boy had a Kawashima-type repair with a bilateral bidirectional Glenn procedure.
|
Introduction
|
|---|
Numerous developments since the successful inception of cavopulmonary connection have improved the survival and functional capacity of patients with univentricular hearts, especially with anomalies of systemic and pulmonary venous drainage, but results of the Fontan operation and its modifications remain suboptimal.
1
–
3
A favorable outcome of Fontan circulation is mainly related to the absence of obstruction in the systemic venous conduit, absence of atrial dysrhythmias, and preservation of ventricular and pulmonary vascular function.
4
The extracardiac Fontan operation with an epicardial tunnel or conduit has been shown to address all of these issues and improve hydrodynamic efficiency.
5
,
6
We describe a technique of diverting blood from the inferior vena cava (IVC) to the pulmonary artery (PA) without the use of cardiopulmonary bypass (CPB).
|
Case Reports
|
|---|
Two patients with cardiac anatomy not suitable for a two-ventricle repair underwent surgery in our institute. The first was a 19-year-old girl who was found to have mesocardia, complete atrioventricular septal defect with a common atrioventricular valve and mild atrioventricular valve regurgitation, double-outlet right ventricle and D-malposed aorta, severe valvular and subvalvular pulmonary stenosis, dilated confluent PA branches, right aortic arch, and IVC draining into the left-sided atrium. An extracardiac Fontan operation was performed without the use of CPB.
The second patient was a 4-year-old boy with heterotaxy syndrome (situs ambiguous) with complete atrioventricular septal defect, severe valvular and subvalvular pulmonary stenosis, anomalous pulmonary venous drainage into the right atrium, bilateral superior venae cavae with absent innominate vein, hepatic interruption, and azygous continuation of the IVC draining into a left superior vena cava (SVC). He had a Kawashima-type repair with a bilateral bidirectional Glenn procedure without the use of CPB.
Surgical repair was performed through a median sternotomy. The SVC was fully mobilized and transected at the cardiac end. It was anastomosed to the top of the right PA as an end-to-side anastomosis using 6/0 poly-propylene continuous and interrupted sutures. A temporary shunt was used between the innominate vein and the right atrium to prevent the SVC pressure from rising above 15 mm Hg. In both patients, there was anomalous IVC drainage. In the first case, as there was a left-sided IVC opening into the left atrium, a 20-mm polytetra-fluoroethylene (PTFE) graft was used. With a side-biting clamp on the IVC, an end-to-side anastomosis was constructed between the PTFE graft and the IVC using a 6/0 PTFE continuous suture. The IVC was interrupted on the cardiac side of the anastomosis. The other end of the graft was anastomosed to the main PA which was divided and sutured proximal to this anastomosis. The left atrial appendage was sutured to a 5-mm opening in the PTFE graft to create a fenestration. The femoral vein pressure was monitored throughout the IVC anastomosis and was below 15 mm Hg. In the second patient with hepatic interruption and azygous continuation of the IVC draining into the left SVC, a temporary venoatrial shunt was created between the external iliac vein and the right atrium using a 14F venous cannula connected to a 1/4 inch tube and passed through a roller pump. Using this shunt, the left SVC was clamped below the left hemi-azygous vein and anastomosed end-to-side to the left PA with a 6/0 polypropylene continuous suture. The main PA was interrupted with a vascular staple. The femoral vein pressure was below 15 mm Hg throughout the procedure. Both patients had excellent hemodynamics and made an uncomplicated recovery.
|
Discussion
|
|---|
The greatest risk of failure of a Fontan operation is in the first month after surgery and it is due to disturbances in ventricular or pulmonary vascular function, arrhythmias, or turbulent flow in the Fontan circuit, resulting in increased venous pressures and poor outcome. The con-struction of an extracardiac conduit in the Fontan circuit is aimed at optimizing perioperative ventricular and pulmonary vascular function in complex lesions. The advantages of this procedure include: ease of operation; avoidance of intraatrial manipulation, an atrial suture line, baffle, or tunnel in the atrium; avoidance of injury to the sinoatrial node; and streamlined flow through a cylindrical prosthesis of uniform caliber.
2
,
4
An extracardiac Fontan operation can be safely performed as a closed heart procedure without the use of CPB in selected cases where additional intracardiac procedures such as atrial septectomy, valve repair, or relief of outflow tract obstruction are not required.
6
Avoidance of CPB has several advantages. Deleterious effects such as a whole body inflammatory response, increased lung water, decreased right ventricular compliance, and increased pulmonary vascular resistance can be avoided. In addition, the cost of the procedure can be substantially reduced. It is technically possible to create a fenestration even in this situation by anastomosing the atrial appendage to the graft. This has been shown to have a positive influence on early outcome, irrespective of patient or procedure variables.
3
Laminar flow is better preserved with good distribution of perfusion to both lungs as turbulence is reduced due to the more uniform caliber and spherical geometry of the extracardiac conduit. The importance of avoiding turbulence and stasis has been amply demon-strated by hydrodynamic and computational modelling studies.
7
The major concern is graft thrombosis, especially if pulmonary vascular resistance increases; the patient needs to be on long-term anticoagulation.
The development of pulmonary arteriovenous malformations in bidirectional cavopulmonary anastomosis is a potential drawback. An unresolved question is how much prograde pulmonary blood flow is required to supply a sufficient hepatic factor to prevent fistulas and stimulate growth of the pulmonary arteries and more favorably redistribute the pulmonary blood flow without causing venous hypertension or systemic ventricular overload.
8
We concluded that the extracardiac Fontan and the Kawashima procedure can be performed without CPB. This could have profound benefits to patients and healthcare providers.
|
References
|
|---|
-
McElhinney DB, Reddy VM, Moore P, Hanley FL. Bidirectional cavopulmonary shunt in patients with anomalies of systemic and pulmonary venous drainage. Ann Thorac Surg
1997; 63
:1676
–84.[Abstract/Free Full Text]
-
Amodeo A, Galletti L, Marianeschi S, Picardo S, Giannico S, Renzi DP, et al. Extracardiac Fontan operation for complex cardiac anomalies: seven years' experience. J Thorac Cardiovasc Surg
1997; 114
:1020
–31.[Abstract/Free Full Text]
-
Gentles TL, Mayer JE Jr, Gauvreau K, Newburger JW, Lock JE, Kupferschmid JP, et al. Fontan operation in five hundred consecutive patients: factors influencing early and late outcome. J Thorac Cardiovasc Surg
1997; 114
:367
–89.[Abstract/Free Full Text]
-
Jacobs ML, Norwood WI Jr. Fontan operation: influence of modifications on morbidity and mortality. Ann Thorac Surg
1994; 58
:945
–52.[Abstract]
-
Sharma S, Goudy S, Walker P, Panchal S, Ensley A, Kanter K, et al. In vitro flow experiments for the determination of optimal geometry of total cavopulmonary connection for surgical repair of children with functional single ventricle. J Am Coll Cardiol
1996; 27
:1264
–9.[Abstract]
-
McElhinney DB, Petrossian E, Reddy VM, Hanley FL. Extracardiac conduit Fontan operation without cardio-pulmonary bypass. Ann Thorac Surg
1998; 66
:1826
–8.[Abstract/Free Full Text]
-
de Leval MR, Dubini G, Migliavacca F, Jalali H, Camporini G, Redington A, et al. Use of computational fluid dynamics in the design of surgical procedures: application to the study of competitive flows in cavopulmonary anastomosis. J Thorac Cardiovasc Surg
1996; 111
:502
–13.[Abstract/Free Full Text]
-
Knott-Craig CJ, Fryar-Dragg T, Overholt ED, Razook JD, Ward KE, Elkins RC. Modified hemi-Fontan operation: an alternative definitive palliation for high-risk patients. Ann Thorac Surg 1995;60:S554–7.
This article has been cited by other articles:
|
|
|
|
 
K. Shivaprakasha, I. Rameshkumar, R. K. Kumar, S. G. Nair, S. Koshy, G. S. Sunil, and S. G. Rao
New technique of right heart bypass in congenital heart surgery with autologous lung as oxygenator
Ann. Thorac. Surg.,
March 1, 2004;
77(3):
988 - 993.
[Abstract]
[Full Text]
[PDF]
|
|
|
TOP
Abstract
Introduction
