Extra cardiac Fontan without cardiopulmonary bypass: techniques and early results

Extracardiac Fontan is currently the preferred final palliation for patients with a univentricular heart. The operation is commonly performed on Cardiopulmonary bypass on a beating heart. In this review, we discuss a protocol for successfully performing this operation without cardiopulmonary bypass. The advantages and pitfalls of this technique are briefly discussed.     

Extracardiac Fontan operation without cardiopulmonary bypass

AIM: The avoidance of cardiopulmonary bypass and aortic cross-clamping in patients possessing single ventricular physiology has potential advantages including preservation of ventricular and pulmonary functions; early extubation, decreased incidence of pleural effusions and decreased requirement of inotropic agents and blood products. In this study, we assessed the postoperative outcome of patients who have undergone extracardiac Fontan operation performed without cardiopulmonary bypass. METHODS: Between March 1999 and August 2002, 10 consecutive patients (6 males and 4 females) underwent extracardiac Fontan operation without cardiopulmonary bypass. The age of patients ranged between 1.5 to 12 (5.2+/-3.1) years. All the patients requiring any intracardiac intervention were excluded from the study. Previous operations of the patients were modified Blalock-Taussig shunt procedure in 3 patients, bidirectional cavopulmonary shunt operation in 2 patients and pulmonary arterial banding in 1 patient. All operations were performed without cardiopulmonary bypass. Bidirectional cavopulmonary anastomosis was performed by using a transient external shunt constructed between the superior vena cava and right atrium. An appropriate sized tube graft was anastomosed to the inferior surface of right pulmonary artery. Finally, inferior vena cava to tube grafts anastomosis was performed with the aid of another external shunt constructed between inferior vena cava and right atrium. During the procedure central venous pressure, blood pressure and arterial oxygen saturation levels were continuously monitored and recorded. RESULTS: The mean intraoperative Fontan pressure was 16.1+/-2.75 mmHg. Intraoperative fenestration was required in 4 patients with a Fontan pressure above 18 mmHg. There were no intra and postoperative deaths. Three patients required mild doses of inotropic support during the postoperative period. All patients were weaned off mechanical ventilation within 24 h. The mean arterial oxygen saturation raised from 74.5+/-4.2% to 93.5+/-2%. Arterial oxygen saturation was 95+/-0.6% in 6 patients without fenestration and 91.2+/-0.5% in 4 patients with fenestration (P=0.001). All patients were in sinus rhythm postoperatively. Only 2 patients required blood transfusion. Two patients suffered from prolonged pleural effusion (more than 7 days). The mean intensive care unit and hospital stay periods were 3.3+/-1.5 and 15.4+/-5.3 days, respectively. CONCLUSIONS: The extracardiac Fontan operation performed without cardiopulmonary bypass provides good results in short and midterm follow-up periods with improved postoperative hemodynamics.     

Miniaturized biocompatible cardiopulmonary bypass for the Fontan procedure

Purpose  

Postoperative inflammatory response and perioperative systemic edema are the risks of failed Fontan circulation. We evaluated the efficiency of the miniaturized, poly-2-methoxyethylacrylate (PMEA)-coated cardiopulmonary bypass (CPB) circuit, which we devised in 2003, in the Fontan circulation.     

Bidirectional Glenn procedure without cardiopulmonary bypass

BACKGROUND: Whether the bidirectional Glenn procedure is better performed without the support of cardiopulmonary bypass is still a matter for debate. In this paper we discuss the indications and methods for bidirectional Glenn shunt without cardiopulmonary bypass. METHODS: Twenty patients with complex cyanotic congenital heart defects underwent a bidirectional Glenn shunt without cardiopulmonary bypass between May 2000 and August 2002. There were 10 male and 10 female patients, the mean age was 2.7 +/- 2.6 years (range, 3 months to 11 years), and the mean weight was 11.0 +/- 6.0 kg (range, 4.5 to 32 kg). The mean transcutaneous oxygen saturation was 74.3% +/- 5.7% before the operation. The Glenn shunt was performed under venoatrial or venopulmonary shunt. RESULTS: All patients survived. Mean superior vena cava clamping time was 24.3 +/- 4.7 minutes, and mean vena cava pressure was 26.9 +/- 5.5 mm Hg during clamping. There were no postoperative neurologic complications. Follow-up echocardiography showed functioning Glenn shunts without any obstruction at the anastomosis. CONCLUSIONS: The adverse effects of cardiopulmonary bypass could be eliminated by this method. This is an advantage during the postoperative recovery, but patients should be strictly chosen.     

The Ross procedure in adults: intermediate-term results

BACKGROUND: The durability of the Ross procedure may be optimized by appropriate geometric matching of the aortic and pulmonary artery roots. We employed a surgical strategy to standardize the operation in order to avoid more readily a geometric mismatch. METHODS: The Ross procedure was performed as a root replacement. Without regard for patient body surface area, the aortic annulus was plicated to 23 mm and externally buttressed with felt. Geometric mismatch of the distal autograft anastomosis was avoided by liberal use of a synthetic interposition graft, and the anastomosis was also externally buttressed with felt. An over-sized pulmonary homograft (27 to 28 mm) was routinely used to reconstruct the right ventricular outflow tract. RESULTS: Forty-four consecutive patients (27 men and 17 women; mean age, 49 +/- 9 years) were operated on between January 1997 and March 2002. Mean follow-up was 38 +/- 5 months. Twenty-nine patients had aortic stenosis and 15 had aortic regurgitation. Aortic annular plication was done in 41 (93%) and an aortic interposition was used in 14 (32%). There were three hospital deaths, with no subsequent deaths. Only 1 patient required reoperation 2.5 years postoperatively from recurrent endocarditis. No patient has more that "trivial" autograft insufficiency, and the mean autograft gradient was 7 +/- 3 mm Hg. No patient has significant pulmonary homograft stenosis. CONCLUSIONS: Geometric matching of the aortic and pulmonary roots may be readily accomplished using a standardized approach to the Ross procedure. In turn, this may optimize the durability of the operation.     

Comparison of lateral tunnel and extracardiac conduit Fontan procedure

The purpose of this study was to compare the outcomes of lateral tunnel (LT) and extracardiac conduit (ECC) Fontan procedures at a single institution. From April 1995 to December 2006, 165 Fontan procedures were performed (67 LT, 98 ECC). Pre-, intra- and postoperative variable values were compared between two different techniques. Operative mortality was 5 (3 LT, 2 ECC). Immediate postoperative transpulmonary gradient (LT 8.5+/-ECC 2.5 vs. 6.6+/-2.4 mmHg) and central venous pressure (LT 18.3+/-3.8 vs. ECC 15.6+/-2.4 mmHg) showed significant difference (P<0.001). The LT patients had a higher incidence of sinus node dysfunction in the postoperative period (22.4% vs. ECC 11.2%; P=0.05). Mean follow-up was 74.1+/-31.5 months in LT, and 31.7+/-28.1 months in ECC patients. There was one late death. Actuarial survival at 10 years is 92% for LT, and 89% for ECC patients (P=0.796). The LT and ECC, both, showed comparable early and mid-term outcomes in operative morbidity and mortality, postoperative hemodynamics, survival. Use of ECC for modified Fontan operation reduces the risk of sinus node dysfunction and shows better outcome of immediate postoperative hemodynamics.     

Anesthetic care during modified fontan procedure without cardiopulmonary bypass

OBJECTIVE: The purpose of this study was to report the anesthetic care of patients during performance of a Fontan procedure without cardiopulmonary bypass (CPB). DESIGN: Retrospective chart review. SETTING: Operating room of a university hospital. PARTICIPANTS: Seven pediatric-patients undergoing inferior vena cava (IVC)-to-pulmonary artery (PA) anastomosis for completion of the Fontan procedure. INTERVENTIONS: Charts were reviewed for anesthetic technique, hemodynamic and ventilatory changes occurring during the procedure, and anesthetic interventions that were provided. MEASUREMENTS AND MAIN RESULTS: The off-bypass Fontan procedure was attempted in 7 patients (age: 26 months-7 years, weight: 13 to 28 kg). Exposure of the PA was not feasible in 1 patient because of a markedly enlarged right atrium. In the remaining 6 patients, before cross-clamping of the PA to allow for the proximal anastomosis between the PA and the conduit, alkalosis (pH > or =7.5) was maintained by the administration of sodium bicarbonate. After PA cross-clamping, fluid administration was necessary in 5 patients and dopamine (3-7 microg/kg/min) was necessary in 4 patients. The minute ventilation was increased by 18 +/- 7% to maintain baseline PaCO2 values. Before the placement of the PA cross-clamp, the end-tidal PaCO2 difference was 7 +/- 4 mmHg and the transcutaneous (TC)-PaCO2 difference was 3 +/- 2 mmHg. The end-tidal PaCO2 difference increased to 14 +/- 6 mmHg during cross-clamping of the PA, whereas no change was noted in the TC-PaCO2 difference. Once the proximal anastomosis was completed, a bridge was placed to redirect blood from the IVC to the right atrium while the IVC was clamped and attached to the distal end of the conduit. After placement of the distal end of the bridge into the IVC, fluid administration to maintain the blood pressure was necessary in 3 patients. In 1 patient, 20 minutes after placement of the bridge, the authors noted a progressive increase in the central venous pressure reading measured from the left femoral vein and the need for the administration of volume to maintain the mean arterial pressure. Examination of the bridge revealed occlusion with thrombus despite an activated coagulation time value of 250 to 300 seconds. The tracheas of 3 of the 6 patients were extubated in the operating room, whereas the other 3 were extubated in the pediatric intensive care unit within 4 hours of completion of the procedure. The 1 patient who required the use of CPB required reintubation and had a protracted intensive care unit course. The other 6 patients were discharged home on postoperative days 7 to 12. CONCLUSIONS: With alteration of the anesthetic technique, the Fontan procedure can be performed in selected patients without the need for CPB.     

Lateral tunnel versus extracardiac conduit Fontan procedure: a concurrent comparison

BACKGROUND: The aim of this study was to compare the outcomes of the lateral tunnel (LT) and extracardiac conduit (ECC) Fontan procedures at a single institution over the same time period. METHODS: From November 1995 through October 2002, 70 Fontan procedures were performed: 37 LT and 33 ECC. All were fenestrated; 96% were staged with a prior superior cavopulmonary connection. Compared with the ECC patients, the LT patients were younger (2.7 +/- 1.1 vs 3.9 +/- 2.5 years; p = 0.01), had a higher incidence of hypoplastic left heart syndrome (57% vs 21%; p < 0.01), and a longer aortic cross-clamp time (55 +/- 13 vs 26 +/- 15 min; p < 0.01). Weight, gender, preoperative cardiac catheterization values, and cardiopulmonary bypass time did not differ between the two groups. RESULTS: Operative mortality was 2.8%, 1 patient in each group (p = 1.0). Over the first 24 hours following operation the mean Fontan pressure, transpulmonary gradient, and common atrial pressure did not differ between LT and ECC patients. The median duration of mechanical ventilation (LT 12 vs ECC 18 hours), intensive care unit stay (LT 2 vs ECC 3 days), chest tube drainage (LT 10 vs ECC 8 days), and hospital stay (LT 11 vs ECC 12 days) did not differ. The ECC patients had a higher incidence of sinus node dysfunction both in the postoperative period (27% vs LT 8%; p = 0.09), and persisting at hospital discharge (10% vs LT 0%; p = 0.02). Mean follow-up was 3.6 +/- 1.6 years in LT, and 3.0 +/- 2.2 years in ECC patients (p = 0.2). There was one late death. Actuarial survival at 5 years is 97% for LT, and 91% for ECC patients (p = 0.4); 96% of patients are in NYHA class I, and 4% in class II, with no difference between groups. Sinus node dysfunction was seen during follow-up in 15% LT vs 28% ECC patients (p = 0.2). CONCLUSIONS: The LT and ECC approaches had comparable early and mid-term outcomes, including operative morbidity and mortality, postoperative hemodynamics, resource use, and mid-term survival and functional status. ECC patients had a higher incidence of sinus node dysfunction early after operation.     

Early results of the extracardiac conduit Fontan operation

BACKGROUND: Among the modifications of the Fontan operation, the extracardiac approach may offer the greatest potential for optimizing early postoperative ventricular and pulmonary vascular function, insofar as it can be performed with short periods of normothermic partial cardiopulmonary bypass and without cardioplegic arrest in most cases. In this study, we reviewed our experience with the extracardiac conduit Fontan operation, with a focus on early postoperative outcomes. METHODS AND RESULTS: Between July 1992 and April 1997, 51 patients (median age 4.9 years) underwent an extracardiac conduit Fontan operation. Median cardiopulmonary bypass time was 92 minutes and has decreased significantly over the course of our experience. Intracardiac procedures were performed in only 5 patients (10%), and the aorta was crossclamped in only 11 (22%). Intraoperative fenestration was performed in 24 patients (47%). There were no early deaths. Fontan failure occurred in 1 patient who was a poor candidate for the Fontan procedure. Transient supraventricular tachyarrhythmias occurred in 5 patients (10%). Median duration of chest tube drainage was 8 days. Factors significantly associated with prolonged resource use (mechanical ventilation, inotropic support, intensive care unit stay, and hospital stay) included longer bypass time and higher Fontan pressure. At a median follow-up of 1.9 years, there was 1 death from bleeding at reoperation. CONCLUSIONS: The extracardiac conduit Fontan procedure can be performed with minimal mortality and morbidity. Improved results may be related to advantages of the extracardiac approach and improved preservation of ventricular and pulmonary vascular function.     

Multiple arterial conduits without cardiopulmonary bypass: early angiographic results

BACKGROUND: Lack of angiographic results and technical difficulty in grafting the vessels in the lateral and posterior walls have reduced interest in myocardial revascularization without cardiopulmonary bypass (CPB). We describe our experience to demonstrate the feasibility of coronary surgical intervention without CPB in multivessel disease. METHODS: From May 21, 1997, through February 1998, 227 patients underwent revascularization with two or more arterial conduits as the first operation: 122 without CPB (group A) and 105 with CPB (group B). Group A included a greater number of high-risk patients. RESULTS: Mean +/- SD anastomoses per patient were 2.5 +/- 0.6 in group A and 2.8 +/- 0.8 in group B (p = NS). No patient died in group A, whereas 1 patient (0.9%) died in group B. The postoperative complication rate was low in both groups, but intensive care unit and in-hospital stays were shorter in group A than in group B (14.1 +/- 7.1 versus 27.3 +/- 36 hours, p < 0.001, and 4.1 +/- 1.6 versus 5.4 +/- 2.4 days, p < 0.001, respectively [group A versus group B]). Sixty-seven patients in Group A (54.9%) underwent postoperative angiography 33 +/- 35 days after operation. The patency rate was 98.9% (98.2% for the marginal branches). CONCLUSIONS: Arterial revascularization of the coronary arteries without CPB is feasible, with results similar to those obtained with CPB. The two techniques, in our opinion, are complementary, not antagonistic.     

Apicoaortic conduit implanted without cardiopulmonary bypass: a useful contingency technique

Apicoaortic conduit implantation is easier and safer with cardiopulmonary bypass. We present an analysis of two cases in which the operation was successfully concluded without the bypass. The first patient had a simultaneous correction of aortic coarctation and tunnelliform subaortic stenosis 8 years ago and is asymptomatic at present. The second patient suffered from hyperlipoproteinemia, calcification of the ascending aorta and femoral arteries and severe aortic stenosis. One month after surgery be suffered cardiac arrhythmia and died. Although this experience is limited, we believe that information about this alternative method may be useful in some cases.