The Extracardiac Total Cavopulmonary Connection For Definitive Conversion to the Fontan Circulation: Summary of Early Experience and Results

A bstract Between July 1991 and March 1993, five children (ages 2 to 6 years) with complex congenital heart disease have undergone a new operation for conversion to the Fontan circulation. This procedure combines a bidirectional Glenn shunt with an extracardiac lateral tunnel (ELT) to carry systemic venous return to the pulmonary arteries (PAs). The ELT was constructed so that the circumference consists of Gore-Tex (2/3) and lateral epicardial atrial wall (1/3). The ELT can be performed with all varieties of single ventricle physiology, as in our patients with tricuspid atresia (n = 3), dextrocardia (n = 1), and situs inversus with levocardia (n = 1). PA reconstruction was required in four patients. At follow-up from 1 to 20 months, all patients are in New York Heart Association Class I and in normal sinus rhythm. Postoperative catheterization has revealed low PA pressures (< 12 ± 1 mmHg) and angiography has shown excellent ELT function with brisk flow into the PAs bilaterally. All patients maintain an O₂ saturation > 94% on room air. The advantages of this new extracardiac modification of Fontan's operation are: (1) aortic cross-clamping is not usually required; (2) incorporation of lateral atrial wall in ELT allows for growth while permitting construction of a fenestration or adjustable atrial septal defect in high risk patients; (3) absence of atriotomy and intraatrial suture lines may decrease late risk of arrhythmias; (4) early or late baffle leaks cannot occur; (5) intraatrial obstruction from the baffle cannot occur; (6) coronary sinus remains in low pressure atrium; and (7) hydrodynamic benefits of the total cavopulmonary connection are preserved. We recommend this procedure for patients undergoing surgical conversion to the Fontan circulation.     

Pulmonary artery to distal bypass for surgery on the descending thoracic aorta

A variety of extracorporeal techniques have been described in surgery of the descending thoracic and thoracoabdominal aorta. We describe an operative approach involving the cannulation of the pulmonary artery for venous drainage in 12 patients undergoing descending thoracic aortic surgery. In-hospital mortality was 17%; there were no in-hospital deaths for elective cases. There were no cases of post-operative paraplegia. Cannulation of the pulmonary artery is a safe and technically simple means of providing venous drainage during cardiopulmonary bypass in aortic surgery. This is an effective approach to distal perfusion in aortic surgery that is associated with excellent flows and avoids cannulating the left side of the heart.     

The recognition, identification of morphologic substrate, and treatment of subaortic stenosis after a Fontan operation. An analysis of twelve patients.

Twelve children were identified with subaortic stenosis after Fontan's operation. All had absent resting and isoproterenol-provoked pressure gradient before the Fontan procedure. Six had a univentricular heart of left ventricular morphology, three had a single ventricle of right ventricular morphology, one had tricuspid atresia with transposition of the great arteries, one had pulmonary atresia, intact ventricular septum, and hypoplastic right ventricle, and one had corrected transposition with hypoplastic systemic ventricle. The median interval between the Fontan operation and the recognition of subaortic stenosis was 2.5 years. Ten patients underwent surgical treatment after a prior Fontan operation: Five had myectomy and enlargement of ventricular septal defect with two operative deaths; two had placement of a valved conduit from the ventricular apex to the descending aorta, and both died postoperatively; two with single ventricle had subaortic myectomy, and one had enlargement of ventricular septal defect and pulmonary aortic connection. Complete heart block developed in only one patient. Postoperative testing with Doppler echocardiography with color flow imaging demonstrated good relief of subaortic stenosis. All six children who survived the operation are well 4 months to 4 years later. Subaortic stenosis is a progressive lesion that may develop after a Fontan operation. Its surgical treatment continues to carry a significant mortality. Myectomy and enlargement of ventricular septal defect achieve direct relief of the obstruction with minimal risk of heart block.     

Choice of venous cannulation for bypass during repair of traumatic rupture of the aorta

BACKGROUND: Choices for venous cannulation for left heart bypass, to assist repair of traumatic rupture of the thoracic aorta, are between the left atrial appendage and pulmonary veins. METHODS: A retrospective chart review was performed of patients who underwent operative repair of ruptured aorta. RESULTS: Over a 15-year period between March 1985 and February 2000, 133 patients were admitted to a level I trauma center with aortic rupture. Of the 50 procedures performed with left heart bypass, the left atrial appendage was cannulated in 19 and pulmonary veins in 31 (four superior, 27 inferior). Complications occurred in 7 of the 19 patients who underwent venous cannulation via the atrial appendage (two ventricular fibrillation, three atrial fibrillation, one pericardial effusion leading to tamponade, and one phrenic nerve injury). Complications occurred in 2 patients who underwent cannulation via pulmonary vein (one atrial fibrillation, one pericardial effusion requiring tapping) (p = 0.02). CONCLUSIONS: Cannulation via the pulmonary veins is associated with a decrease in complication rates compared with cannulation of the atrial appendage.     

The infant with single ventricle and excessive pulmonary blood flow: results of a strategy of pulmonary artery division and shunt

BACKGROUND: The infant with a single ventricle and excessive pulmonary blood flow requires early protection of the pulmonary vascular bed to insure suitability for a subsequent Fontan procedure. The traditional approach, pulmonary artery banding, has had disappointing results. We have pursued an alternate strategy: division of the pulmonary artery, and placement of a systemic-to-pulmonary artery shunt. Potential sites of systemic outflow tract obstruction are simultaneously bypassed, by either a Damus-Kaye-Stansel, or modified Norwood procedure. METHODS: From January 1996 to June 2001, 22 infants were treated by this strategy. Patients with hypoplastic left heart syndrome were excluded. Median age was 18 days (range 2 days to 6 months). In addition to pulmonary artery division and shunt, 3 of 22 patients underwent a Damus-Kaye-Stansel procedure, and 13 of 22 patients underwent a modified Norwood procedure. RESULTS: There were no operative deaths, and one late death. Actuarial survival beyond 30 months was 90%. At follow-up catheterization in 22 patients, median transpulmonary gradient was 7 mmHg (range 4 to 18), and median pulmonary vascular resistance 1.9 Wood units (range 0.9 to 3.3). Twenty-one patients have undergone a subsequent bidirectional superior cavopulmonary connection, and 6 a Fontan procedure, with no deaths. No patient developed subaortic stenosis, or aortic arch obstruction. Neoaortic insufficiency was none or trivial in 12 patients, mild in 3, and moderate in 1. CONCLUSIONS: In patients with a functional single ventricle and excessive pulmonary flow, a strategy of pulmonary artery division and shunt, along with prophylactic bypass of systemic outflow obstruction, carries low operative and midterm mortality. It provides consistent protection of the pulmonary vascular bed, avoids subaortic stenosis and aortic arch obstruction, minimizes neoaortic insufficiency, and ensures suitability for progression along a Fontan pathway. These results provide a comparison for alternate strategies, including pulmonary artery banding.     

Extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock in children

Size limitations and technical barriers prohibit the use of many conventional mechanical circulatory support systems for postcardiotomy ventricular dysfunction in pediatric populations. Extracorporeal membrane oxygenation (ECMO), frequently used to treat neonatal respiratory failure, can provide cardiac support and is effective treatment of postoperative myocardial failure in children. From 1981 to 1987, 10 patients aged 2 days to 5 years were maintained on ECMO for 15 to 144 hours (mean duration, 92 +/- 16 hours) after cardiotomy. Operative procedures included repair of tetralogy of Fallot (2 patients), closure of a ventricular septal defect (2), the Senning procedure for transposition of the great arteries (1 patient), repair of interrupted aortic arch with closure of a ventricular septal defect (1), repair of a partial atrioventricular septal defect (2), closure of a ventricular septal defect with excision of an anomalous muscle bundle (1), and the Fontan procedure (1). Venoarterial ECMO was established in all 10 children. Six patients underwent transthoracic right atrium-ascending aorta cannulation, 3 had right internal jugular vein-right common carotid artery cannulation through a cervical incision, and 1 had right internal jugular vein-left axillary artery cannulation. Eight of the 10 patients were successfully weaned from ECMO, and 7 are long-term survivors. There were 3 deaths; 1 was caused by cardiac and acute renal failure complicated by sepsis two days after decannulation, another occurred 19 days after atrioventricular septal defect repair, and 1 was caused by massive pulmonary hemorrhage. Major hemorrhage developed in 3 patients while on ECMO; 2 required premature decannulation for mediastinal bleeding from operative sites and ultimately survived, and 1 died of respiratory failure as a result of endobronchial bleeding. We conclude that the use of ECMO in pediatric populations for transient postoperative ventricular dysfunction improves survival with limited overall morbidity.     

Growth of the hypoplastic ascending aorta after radical palliation

Surgical treatment of hypoplasia of the ascending aorta is a difficult problem. An approach using proximal pulmonary artery to distal aorta bypass with distal pulmonary artery banding was employed in 19 patients with an ascending aorta less than 6 mm in diameter but a patent aortic outflow. There were 11 male and 8 female neonates and infants, and weight ranged from 2 to 4.5 kg (median weight, 3.5 kg). Four patients had transposition of the great arteries, 12 had subaortic stenosis, and 5 had interrupted aortic arch. There was one operative death. Cerebral cyanosis developed in 3 of the 4 patients with transposition of the great arteries and necessitated additional operations within the first year postoperatively. Therefore, palliation with a pulmonary artery to descending aorta conduit and banding was abandoned in such patients. All 14 surviving patients with normally related great arteries had successful palliation and growth of left heart structures. Subsequent procedures included a Fontan/Damus procedure in 1 patient, patch aortoplasty and pulmonary arterioplasty in 5 patients, arch reconstruction with aortic valvulotomy and pulmonary arterioplasty in 2, double arch reconstruction in 2, and simple patch aortoplasty with plans for subsequent pulmonary arterioplasty and ventricular septal defect closure in 1. Results demonstrate that in patients with a hypoplastic ascending aorta, this radical method of palliation can result in growth of right and left heart structures and thus provides the possibility of biventricular repair.     

New surgical approach "intrapulmonary septation technic" for Fontan candidates with unilateral pulmonary arterial hypoplasia and/or pulmonary venous obstruction

Unilateral pulmonary arterial hypoplasia and/or pulmonary venous obstruction are serious hazards for Fontan candidates. For these patients, we have started new surgical approach "intrapulmonary septation technic". This consists of 3 components; (A) partial right heart bypass to well-grown side, (B) mandatory pulmonary blood flow to low-capacity side, (aorto-pulmonary shunt or others) and (C) a patch between partial right heart bypass and mandatory pulmonary blood flow. Thirteen patients underwent the approach. The source of partial right heart bypass was brought from superior vena cava (11 patients), inferior vena cava (1 patient) and fenestrated Fontan (1 patient). The mandatory pulmonary blood flow was supplied by aorto-pulmonary shunt (11 patients), pulmonary arterial banding (1 patient) and native pulmonary valve stenosis (1 patient). We added pulmonary artery enlargement (9 patients), release of pulmonary venous obstruction (8 patients) and/or atrio-ventricular valve plasty (5 patients), simultaneously. No hospital death. Early post-operative course was uneventful in all cases except 1, as pulmonary blood flow to low-capacity side had increased gradually after this intervention. Eight patients had reached Fontan operation. In this approach, nearly whole pulmonary artery can grow without any affect of volume overload through well-grown side from collateral arteries of low-capacity side. All procedures of "intrapulmonary septation technic" and reconstruction of pulmonary artery in Fontan operation can be easily performed in larger pulmonary artery of well-grown side, eliminating need for extensive dissection.     

Outcomes of tricuspid atresia in the Fontan era

BACKGROUND: Whereas indications expand and results improve with increasing refinements to the Fontan procedure the overall impact on outcomes related to tricuspid atresia remains suboptimally defined. METHODS: We reviewed 225 consecutive patients presenting between 1971 and 1999. All patients had classic tricuspid atresia with absent right atrioventricular connection and with D-transposition of the great arteries in 21%, pulmonary outflow obstruction in 75%, and aortic outflow obstruction in 11%. RESULTS: Ten patients died before any intervention and 3 patients were lost to follow-up. Palliative procedures (includes 151 with systemic shunt, 27 pulmonary artery banding, 60 venous shunt) were performed in 203 patients, with 44 deaths, 8 patients awaiting Fontan, 12 patients Fontan contraindicated, and 11 patients lost-to-follow-up. A total of 137 patients had the Fontan procedure (9 patients without previous procedures) with 7 early deaths, 11 late deaths, and 3 patients progressing to heart transplantation. Total survival for the cohort was 90% at the age of 1 month, 81% at 1 year, 70% at 10 years, and 60% at 20 years with no significant change over the time period. Independent factors associated with ineligibility or death without Fontan (n = 68, 30%) included earlier birth date, lower birth weight, presence of aortic arch anomaly and greater right ventricular hypoplasia, and no palliative procedure. There were no significant changes in mortality with Fontan over the study time period with survival of 95% at 1 month, 93% at 1year, and 82% at 10 years. CONCLUSIONS: Improvements in outcomes with tricuspid atresia will require attention to management and risk factors before Fontan.     

Fontan's operation: is aspirin enough? Is coumadin too much?

BACKGROUND: Thromboembolism after Fontan's operation is attributed to low flow states, stasis in venous pathways, right to left shunts, blind cul-de-sacs, prosthetic materials, atrial arrhythmias, and hypercoagulable states. We assessed the efficacy of a strategy to reduce thromboembolic events including aspirin anticoagulation. METHODS: From January 1996 through December 2000, 72 patients underwent Fontan procedures. Management included (1) avoidance of direct caval cannulation and central venous lines, (2) inotropic support for 48 to 72 hours to optimize cardiac output, (3) aortopulmonary anastomosis or suture closure of patent pulmonary valves, and (4) administration of aspirin (81 mg per day) beginning on postoperative day one. No other anticoagulation strategies were used. Surveillance included intraoperative and postoperative transesophageal echo, transthoracic echo at discharge, at first reevaluation, and at 6 month intervals, and catheterization 1 year after surgery. RESULTS: There were no early or late deaths. Follow-up was completed with 2,882 patient-months and a mean of 40 months. There were no documented thromboembolic events; however, all suspicious occurrences were investigated by echo and brain imaging. There were no hemorrhagic events or aspirin-related complications. CONCLUSIONS: Low dose aspirin can be used safely in young patients with Fontan connections. At intermediate follow-up, the strategies described appear effective in preventing thromboembolic complications. Routine use of more aggressive anticoagulation regimens seems unwarranted.     

Extrathoracic Approach for Reconstruction of Subclavian and Vertebral Arteries

One hundred extrathoracic arterial reconstructions were performed on 98 patients with occlusions or stenoses of the subclavian or vertebral arteries: 52 bypasses, 18 transpositions of the subclavian artery to the common carotid artery, 13 endarterectomies and 17 operations involving two or more simultaneous reconstructions. The operative mortality was 1% (one patient). In 2 patients hemiplegia occurred as a complication of carotidsubclavian bypass operation. Six patients had a nerve injury as an operative complication: 1 lesion of the brachial plexus, 3 lesions of the recurrent nerve, and two lesions of the phrenic nerve (one patient also had Horner's syndrome). Immediate thrombosis of the operated arteries developed in 7 patients, 2 of whom were re-operated on. During the follow-up period (mean 4.5 years), six additional operations were performed because of failure of the first operation: the bypass graft was thrombosed in 5 of these cases and in one case a venous bypass graft with insufficient flow was replaced by a prosthesis. One patient underwent reconstruction of the contralateral side because of residual symptoms. In addition, 1 carotid endarterectomy, 2 thoracic sympathectomies, 4 coronary artery reconstructions and 8 lower limb arterial reconstructions were performed during the follow-up period. There were 17 late deaths, 9 of which were due to coronary artery disease. Of the 80 survivors 79% were satisfied with the operative result. The bypass was considered patent in 68%.     

Modified Fontan operation for a single ventricle with a nonconfluent pulmonary artery]

A 8-year-old boy with a double inlet right ventricle with a non-confluent pulmonary artery was operated on with a modified Fontan operation. He had right isomerism, right aortic arch, bilateral superior caval veins, and left-sided inferior caval vein. Hepatic veins were separately drained to the right-side atrium. Left Blalock-Taussig shunt and right central shunt operations had been previously performed. Firstly, we had reconstructed the central pulmonary artery with a 16 mm porcine pericardial roll to unify the nonconfluent pulmonary arteries. Secondly, about 2 months after the first operation, we performed a modified Fontan operation. Systemic venous return from the inferior caval vein and the hepatic veins were drained to a reconstructed pericardial roll with an intraatrial Gore-Tex graft, and bilateral superior caval veins were also anastomosed to the roll. The structure of the pulmonary arterial system is one of the most important factors to determine the outcome of a modified Fontan operation. Even if the central pulmonary artery is absent, however, a modified Fontan operation is applicable for the patient whose peripheral pulmonary arteries have enough growth.     

The bidirectional cavopulmonary shunt.

The bidirectional cavopulmonary shunt improves systemic arterial oxygen saturation without increasing ventricular work or pulmonary vascular resistance. Since 1983, 17 patients have undergone a cavopulmonary shunt procedure (five primary operations, 12 secondary operations). Diagnoses were single ventricle complex (n = 4), hypoplastic right heart syndrome (n = 10), and hypoplastic left ventricle (n = 3). Age at primary operation ranged from 3 1/2 to 30 months (median 6 months). Weight ranged from 3.5 to 9.7 kg. Age at secondary operation ranged from 10 months to 14 years (median 15 months). Seven cavopulmonary shunt operations were performed without cardiopulmonary bypass (six via thoracotomy and one via sternotomy) and 10, with cardiopulmonary bypass. All patients in the bypass group had additional procedures: takedown of modified Blalock-Taussig shunt, seven patients; revision of right ventricular outflow tract, four patients; reconstruction of pulmonary arteries, four patients; tricuspid valvuloplasty, one patient; and Damus procedure, one patient. There was one (1/17) operative death (Damus procedure). One patient required early revision. Follow-up ranges from 1 to 53 months (median 23 months). Twelve of 16 had a good to excellent late result, with a rise in mean arterial oxygen saturation from 69% to 83%. Three patients died late (4 to 53 months) (pulmonary vascular disease, pulmonary arteriovenous malformations, and pneumonia, one patient each). There was one late failure (converted to Glenn shunt). The cavopulmonary shunt is an excellent palliative procedure when right atrium-pulmonary artery connection (modified Fontan) must be deferred because of age, weight, or anatomic considerations. Five patients have undergone right atrium-pulmonary artery connection later. In addition, at the time of the modified Fontan operation, the cavopulmonary shunt approach may optimize the anatomic connection (eight additional patients).     

Surgical repair of total anomalous pulmonary venous connection in neonates and infants--prevention for pulmonary venous obstruction at the site of anastomosis

From October, 1980, to June, 1987, thirty-eight infants less than one year old underwent correction for total anomalous pulmonary venous connection (TAPVC). Overall operative mortality and late mortality were 13% and 6%, respectively. Residual pulmonary hypertension was noted in 4 patients: three had pulmonary venous obstruction at the site of atrial anastomosis (PVOA) and one had supracardiac (Ia) lesion left after repair of mixed type (IV: Ia + III) of TAPVC. Two late deaths occurred in these with PVOA. Twenty-two patients with supracardiac (I) or infracardiac (III) TAPVC were divided into three groups according to the technical development in atrial anastomosis: the large anastomosis in which venous incision reached into at least one pulmonary vein beyond common pulmonary vein and the continuous running suture were used in 10 patients (group 1), the appropriate size of anastomosis in which venous incision limited within the common pulmonary vein and the continuous running suture used in 4 patients (group 2), and the appropriate size of anastomosis and the interrupted suture in 8 patients (group 3). PVOA were 3 (33%) in group 1, but 0 (0%) in group 2 and 3. Two late death occurred all in group 1 with PVOA. Cardiopulmonary bypass time and aortic clamp time in group 3 were 91 min and 74 min respectively, which did not become longer than those in both group 1 and group 2. Interrupted suture technique does not make operating time longer than continuous running suture one. PVOA is one of the important factors predicting late operative result.(ABSTRACT TRUNCATED AT 250 WORDS)     

Brachial artery cannulation facilitates lower ministernotomy cardiac surgery

BACKGROUND: Lower ministernotomy has become a more popular approach for many heart operations. However, cannulation of the ascending aorta may cause serious complications. Femoral and brachial arteries have been used for alternative arterial cannulation sites. MATERIALS AND METHODS: The lower ministernotomy approach was used in 65 patients. Ascending aortic cannulation was performed in group 1 (n = 38), femoral cannulation in group 2 (n = 12), and brachial cannulation in group 3 (n = 15) patients. Brachial artery diameter was measured preoperatively by Doppler ultrasound in the preoperative period. RESULTS: Average cross-clamp time for femoral and brachial artery cannulated patients was significantly shorter than in patients in group 1 (31 +/- 9 and 35 +/- 6 minutes, respectively) (p = 0.034). Total cardiopulmonary bypass (CPB) time was 56 +/- 11 minutes for group 1, 39 +/- 7 minutes for group 2, and 41 +/- 5.4 minutes for group 3 (p = 0.041). Operation time was 112 +/- 24, 88 +/- 12, and 91 +/- 11 minutes for the groups 1, 2, and 3, respectively. There was also statistically significant difference between group 1 and group 3 comparisons with regard to CPB time (p = 0.041). Difficult exposure from many cannulas impedes access and lengthens the operation in group I. Superficial wound infection developed in seven patients in group 1, one patient in group 2, and one patient in group 3. CONCLUSION: Cannulation of the brachial artery is superior to the femoral due to possible infection and lymph leakage with the latter and both are superior to central cannulation when lower ministernotomy is performed. By avoiding the difficulties of central aortic cannula placement the operative time is decreased and possible wound edge is protected as lesser exposure is required.     

Anatomical risk factors for mortality and cardiac morbidity after arterial switch operation

Background. The arterial switch operation (ASO) is the treatment of choice for transposition of the great arteries.

Methods. Anatomical risk factors on mortality and morbidity were analyzed retrospectively in 312 patients who underwent ASO between 1982 and 1997.

Results. Survival was 95%, 92%, and 92% after 30 days, 5, and 10 years, respectively. Operative survival improved after 1990 to 97% (p < 0.001). Risk factors for operative mortality were complex anatomy (p = 0.018), coronary anomalies (p = 0.008), and prolonged bypass time (p < 0.001). Determinants of late mortality were coronary distribution (p = 0.03), position of the great arteries (p = 0.0095), bypass time (p = 0.047), and aortic coarctation (p = 0.046). After a follow-up of 3.6 ± 2.7 years (0.1 to 14.9 years), 98% had good left ventricle function, 94% were in sinus rhythm, 2.4% had moderate to severe pulmonary stenosis, 0.3% had significant aortic regurgitation, and 1% had coronary stenosis. Freedom from reoperation was 100%, 96%, and 94% after 1, 5, and 10 years, respectively. No preoperative anatomic parameter correlated with long-term morbidity.

Conclusions. ASO can be performed with low operative mortality (< 5%) and long-term morbidity. Malformations associated with complex transposition of the great arteries influence early and late mortality.     

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.     

Extrathoracic cannulation of the left common carotid artery in thoracic aorta operations through a left thoracotomy: preliminary experience in 26 patients

BACKGROUND: In aortic operations performed through a left thoracotomy, which require total bypass and deep hypothermic circulatory arrest, femoral artery cannulation is commonly used for arterial perfusion. This route limits the time of safe circulatory arrest and is associated with the risks of retrograde embolization or, in the case of aortic dissection, malperfusion of the vital organs. To overcome these problems, we have used cannulation of the extrathoracic left common carotid artery to ensure a central a route of arterial perfusion in these operations. The preliminary results are presented. METHODS: Between December 1999 and April 2001, we used left common carotid artery cannulation in 26 operations on the thoracic aorta performed through a posterolateral thoracotomy with an open technique during deep hypothermic circulatory arrest. Institutional review board approval and informed consent were obtained. The indications included perforating atherosclerotic ulcer (n = 5), chronic aortic aneurysm (n = 9), acute type B aortic dissection (n = 3), and chronic dissection of the thoracic aorta (n = 9). Transcranial Doppler ultrasonographic monitoring of both the right and left middle cerebral arteries was used to assess the adequacy of cerebral bihemispheric perfusion and to determine the differences in blood flow velocities throughout the procedure. RESULTS: Left common carotid artery cannulation was successful in all patients. All patients awoke from the operation, and none had cerebrovascular accidents. None died in the hospital, and complications related to carotid artery cannulation were not observed. None of the patients experienced postoperative paraplegia. In all patients transcranial Doppler monitoring indicated the absence of cerebral embolic phenomena throughout the entire procedure. Significant differences in middle cerebral artery flow velocities were observed at different phases of the procedures and between the right and left middle cerebral arteries during carotid cannulation and during selective cerebral perfusion. Nevertheless, the maximal drop of right middle cerebral artery blood velocity during selective perfusion through the left common carotid artery was within 50% of the left middle cerebral artery velocity, indicating adequate bihemispheric perfusion. CONCLUSIONS: In patients undergoing aortic operations through a left thoracotomy, extrathoracic left common carotid artery cannulation was a safe and effective means of providing proximal arterial inflow during cardiopulmonary bypass, which can be used to selectively perfuse the brain, as well as to prevent embolic phenomena in the arch vessels.     

Early results of the fontan procedure in one hundred consecutive patients with hypoplastic left heart syndrome

OBJECTIVES: The purpose of this study was to review a large, single institutional experience with the Fontan procedure for patients with hypoplastic left heart syndrome. METHODS: One hundred consecutive patients with "classic" hypoplastic left heart syndrome underwent Fontan palliation between February 1992 and April 1998. Patient demographic, morphologic, and procedural variables were examined and analyzed. In particular, two different surgical techniques were used: technique I (February 1992 to December 1995) employed cardiopulmonary bypass and moderate systemic hypothermia, and technique II (December 1995 to April 1998), profound hypothermia and circulatory arrest. A retrospective review of medical records was performed and variables were examined and analyzed. RESULTS: Hospital survival for the entire cohort was 89% (95% CI 83%-95%). The technique of operation, cardiopulmonary bypass time, and aortic crossclamp time were each strongly associated with survival. Survival for patients treated by technique I was 79% (95% CI 68-91%; n = 48) and for those treated by technique II, 98% (95% CI 94%-100%; n = 52). Cardiopulmonary bypass and crossclamp times were also highly correlated with time to extubation and length of intensive care unit stay. Preoperative pulmonary artery pressure was correlated with survival; preoperative oxygen saturation, right atrial pressure, pulmonary vascular resistance, pulmonary artery size, extent of aortopulmonary artery collaterals, and echocardiographic estimates of ventricular function and tricuspid regurgitation were not correlated with survival. CONCLUSIONS: Our recent experience with Fontan palliation for patients with hypoplastic left heart syndrome suggests that it is attended by low perioperative mortality. The precise operative technique used appears to be an important determinant of outcome, with the duration of cardiopulmonary bypass and crossclamping being particularly significant.     

Right ventricular dynamic cardiomyoplasty for the univentricular heart with pulmonary hypertension

OBJECTIVES: We conducted an acute experimental study to test the feasibility of dynamic cardiomyoplasty in a setting of modified Fontan procedure for univentricular heart with pulmonary hypertension to obtain a possible proxy for high-risk Fontan candidates. METHODS: After electrical preconditioning of the left latissimuss dorsi for 6 weeks in 8 dogs, the right ventricular cavity was totally obliterated with concomittent closure of the tricuspid valve and right pulmonary artery. Modified Fontan circulation was established with the aortic homograft anastomosed between the right atrium and pulmonary trunk, incorporated with a pericardial pouch as a compression chamber (neoright ventricle) fixed onto the epicardial surface of the ventricle. After cardiopulmonary bypass termination, a latissimus dorsi was applied to wrap the pericardial pouch and ventricle clockwise and stimulated with a trained-pulse (25 Hz) at 1:1 synchronization ratio with cardiac beats. RESULTS: Profound right heart failure was noted during Fontan circulation in increased pulmonary vascular resistance (11 +/- 3.2 Wood units), whereas graft pacing showed significant augmentation of systolic pulmonary pressure by 54 +/- 12%, the mean pulmonary flow by 68 +/- 23%, and aortic pressure by 23 +/- 5% at a physiological range of central venous pressure (13.2 +/- 0.7 mmHg). Right heart function curve analysis confirmed marked augmentation of right heart performance, restoring almost normal pulmonary circulation. These functional benefits were sustained up to 4 hours in 4 animals until experiments were terminated. CONCLUSIONS: Dynamic cardiomyoplasty in a modified Fontan procedure is a viable surgical option for univentricular heart, not a Fontan candidate.