Factors Associated With Prolonged Recovery After the Fontan Operation

Salvin, Joshua W.; Scheurer, Mark A.; Laussen, Peter C.; Mayer, John E.; Nido, Pedro J. del; Pigula, Frank A.; Bacha, Emile A.; Thiagarajan, Ravi R.

doi:10.1161/circulationaha.107.750596

Cited by 67 publications

(57 citation statements)

References 30 publications

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“…3,4 Eventually, the patient that develops failing Fontan circulation may require cavopulmonary assist and heart transplantation. 6 In recent years, research has been focused on the development of a cavopulmonary assist (CPA) device for bridge to heart transplantation or destination therapy.…”

Section: Discussionmentioning

confidence: 99%

A Practical and Less Invasive Total Cavopulmonary Connection Sheep Model

et al. 2014

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Our goal is to develop a less invasive total cavopulmonary connection (TCPC) sheep model for testing total cavopulmonary assist (CPA) devices. Thirteen sheep underwent a right 4th intercostal lateral thoracotomy. In series I (n=6), a polytetrafluoroethylene (PTFE) extracardiac conduit (ECC) was connected to inferior vena cava (IVC) and superior vena cava (SVC) by end to side anastomosis. The SVC/IVC remained connected to right atrium (RA). A PTFE graft bridged ECC to right pulmonary artery (RPA). Clamps between SVC/IVC anastomoses and RA diverted total venous blood to pulmonary circulation. In series II (n=7), temporary bypasses between SVC/IVC to RA allowed SVC/IVC to be cut off from RA for better RPA exposure. The ECC-SVC/IVC were end-end anastomosed and ECC-RPA side-side anastomosed for total SVC/IVC to PA conversion. In each series, one sheep died of bleeding. In 5 sheep in series I and 6 sheep in series II, the TCPC model was successfully created with significantly increased central venous pressure and significantly decreased pulmonary artery pressure/arterial blood pressure. Our acute TCPC sheep model has a less traumatic right thoracotomy with no cardiopulmonary bypass and less blood loss with no blood transfusion, facilitating future long-term CPA device evaluation.

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Section: Discussionmentioning

confidence: 99%

A Practical and Less Invasive Total Cavopulmonary Connection Sheep Model

et al. 2014

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“…Additionally, chest tube drainage has been well documented as a complication after the Fontan operation that prolongs postoperative recovery, extends the hospital length of stay, and contributes to morbidity [13, 18]. Duration of chest tube drainage was defined as the number of days until the last remaining pleural chest tube was removed.…”

Section: Methodsmentioning

confidence: 99%

“…These modifications have allowed a broad cross-section of patients with single-ventricle physiology to undergo successful Fontan palliation with excellent survival rates [1, 13]. However, despite low mortality rates, patients who undergo the Fontan operation continue to remain at considerable risk for prolonged postoperative recovery complicated by persistent pleural effusions, ventricular dysfunction, arrhythmias, and protracted mechanical ventilation [18, 21]. …”

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confidence: 99%

Reduction in Postoperative High-Density Lipoprotein Cholesterol Levels in Children Undergoing the Fontan Operation

et al. 2012

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Despite the emerging relevance of high-density lipoprotein (HDL) in the inflammatory cascade and vascular barrier integrity, HDL levels in children undergoing cardiac surgery are unexplored. As a measure of HDL levels, the HDL-cholesterol (HDL-C) in single-ventricle patients was quantified before and after the Fontan operation, and it was determined whether relationships existed between the duration and the type of postoperative pleural effusions. The study prospectively enrolled 12 children undergoing the Fontan operation. Plasma HDL-C levels were measured before and after cardiopulmonary bypass. The outcome variables of interest were the duration and type of chest tube drainage (chylous vs. nonchylous). The Kendall rank correlation coefficient and the Wilcoxon rank sum test were used. There were 11 complete observations. The median preoperative HDL-C level for all the subjects was 30 mg/dl (range, 24-53 mg/dl), and the median postcardiopulmonary bypass level was 21 mg/dl (range, 14-46 mg/dl) (p = 0.004). There was a tendency toward a moderate inverse correlation (-0.42) between the postcardiopulmonary bypass HDL-C level and the duration of chest tube drainage, but the result was not statistically significant (p = 0.07). In the chylous effusion group, the median postcardiopulmonary bypass HDL-C tended to be lower (16 vs. 23 mg/dl; p = 0.09). After the Fontan operation, the plasma HDL-C levels in children are significantly reduced. It is reasonable to conclude that the reduction in HDL-C reflects reduced plasma levels of HDL particles, which may have pertinent implications in postoperative pleural effusions given the antiinflammatory and endothelial barrier functions of HDL. KeywordsFontan; HDL-C; High-density lipoprotein-cholesterol Since the original description of the Fontan operation by Fontan and Baudet [8] in 1971, the procedure has undergone significant improvements in both the surgical and medical managements. These modifications have allowed a broad cross-section of patients with single-ventricle physiology to undergo successful Fontan palliation with excellent survival rates [1,13]. However, despite low mortality rates, patients who undergo the Fontan operation continue to remain at considerable risk for prolonged postoperative recovery complicated by persistent pleural effusions, ventricular dysfunction, arrhythmias, and protracted mechanical ventilation [18,21].Heart catheterization and echocardiographic evaluations are routinely performed before the Fontan operation in efforts to predict how the lungs and heart will interact. Yet, despite this practice, predicting the early postoperative course remains difficult, and it is becoming increasingly evident that catheterization hemodynamic data are not consistently associated with early postoperative outcomes [5,16]. This suggests the existence of other unexplored variables that place Fontan patients at risk for prolonged postoperative recovery despite acceptable hemodynamic criteria.In recent years, reductions in high-density lipoprotein (HDL) ...

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“…Fontan patients, who rely on passive circulation of the venous blood through the lungs, are particularly sensitive to these changes [9]. Prolonged CPB, as a surrogate risk factor for the need for additional procedures to correct associated lesions, may increase the risk and has been associated with poor outcomes after the Fontan operation [4, 10–12]. Some groups have focused on reducing or eliminating the use of CPB during the Fontan operation to minimize the impact of the inflammatory response associated with the use of CPB and to improve post-Fontan hemodynamics [7, 8].…”

Section: Commentmentioning

confidence: 99%

Early Results of the “Clamp and Sew” Fontan Procedure Without the Use of Circulatory Support

Shinkawa

Anagnostopoulos

Johnson

et al. 2011

The Annals of Thoracic Surgery

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Background A modification of the Fontan operation was recently applied, which includes anastomoses of the extra-cardiac conduit to the right pulmonary artery and inferior vena cava using simple clamping with no additional circulatory support, venous shunting, pulmonary artery preparation, or prior maintenance of azygos vein patency. The objective of this study is to assess the outcomes of this novel off-pump “clamp and sew” Fontan procedure. Methods This is a retrospective review of all patients having a Fontan procedure between January 2009 and October 2010 at a single institution. Results Twelve patients had a Fontan procedure with the use of cardiopulmonary bypass (CPB group), and 12 had an off-pump Fontan procedure (off-pump group). Preoperative demographic and hemodynamic data were similar except for higher mean pulmonary artery pressure in the CPB group (12.2 ± 1.6 mm Hg versus 9.9 ± 2.4 mm Hg; p = 0.02). No patients in the off-pump group required conversion to CPB. The mean inferior vena cava clamp time in the off-pump group patients was 10 ± 3 minutes. There were no early or midterm deaths. No patients exhibited postoperative hepatic or renal dysfunction. Postoperative maximal serum creatinine and aspartate transaminase were significantly lower in the off-pump group compared with the CPB group (0.59 ± 0.12 versus 0.77 ± 0.22 mg/dL; p = 0.03 and 35.5 ± 8.3 versus 53.1 ± 19.0 U/L; p = 0.02, respectively). At median follow-up of 13 months (range, 1 to 20 months), all but 1 patient in the CPB group are in New York Heart Association class I with unobstructed Fontan circulation. Conclusions The clamp and sew technique for completion of an extracardiac conduit Fontan procedure appears safe and feasible for selected patients.

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Factors Associated With Prolonged Recovery After the Fontan Operation

Cited by 67 publications

References 30 publications

A Practical and Less Invasive Total Cavopulmonary Connection Sheep Model

A Practical and Less Invasive Total Cavopulmonary Connection Sheep Model

Reduction in Postoperative High-Density Lipoprotein Cholesterol Levels in Children Undergoing the Fontan Operation

Early Results of the “Clamp and Sew” Fontan Procedure Without the Use of Circulatory Support

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