Results of staged total cavopulmonary connection for functionally univentricular hearts; comparison of intra-atrial lateral tunnel and extracardiac conduit

Robbers‐Visser, Daniëlle; Miedema, Martijn; Nijveld, A.; Boersma, Eric; Bogers, Ad J.J.C.; Haas, Felix; Helbing, Willem A.; Kapusta, Livia

doi:10.1016/j.ejcts.2009.10.016

Cited by 64 publications

(48 citation statements)

References 23 publications

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“…547,548 Some cohort studies report anticoagulation or aspirin to be better than no therapy in terms of thrombotic complications, 558 although others question this fi nding. 559 The only randomized trial performed compared aspirin (5 mg/kg per day) to initial UFH followed by warfarin (target INR, 2.5; range, 2.0-3.0) as primary prophylaxis for 2 years postFontan surgery. The study found no difference in thrombosis (cumulative thrombosis rates, 19% at 2 years) or bleeding.…”

Section: Fontan Surgerymentioning

confidence: 99%

Antithrombotic Therapy in Neonates and Children

Monagle

Chan

Goldenberg

et al. 2012

Chest

1,269

559

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Section: Fontan Surgerymentioning

confidence: 99%

Antithrombotic Therapy in Neonates and Children

Monagle

Chan

Goldenberg

et al. 2012

Chest

1,269

559

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“…6,15,16 In a direct comparison, at 6-year follow-up, the freedom from arrhythmia was 83% for the lateral tunnel Fontan and 92% for the extracardiac Fontan (Pϭ0.022). 17 Amodeo et al 18 also demonstrated a 5-year freedom from arrhythmia rate of 92% with the extracardiac Fontan. Another study looking specifically at the extracardiac Fontan reported new-onset transient supraventricular arrhythmias in 10% of patients in the early postoperative period.…”

Section: Advantage 3: Reduced Arrhythmiasmentioning

confidence: 94%

Is the Extracardiac Conduit the Preferred Fontan Approach for Patients With Univentricular Hearts?

Kogon

2012

Circulation

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W ith improvements in technology, operative technique, and critical care medicine, more and more children with congenital heart disease are surviving into adulthood. As they age, these patients are providing physicians with new challenges, and we are realizing the long-term consequences of our previous interventions. This oftentimes has changed the mode of treatment for subsequent children. Response by Khairy and Poirier on p 2515Fontan palliation for single-ventricle patients was first described in 1971. 1 The original approach was in the form of a classic atriopulmonary Fontan connection, bypassing the nonfunctional right ventricle. After recognizing the long-term complication of an atriopulmonary connection (right atrial dilation, arrhythmias, and thrombus formation), modifications have been made. The atriopulmonary connection has been abandoned in favor of modified Fontan anatomy and physiology.The modified Fontan can be performed by the use of an extracardiac conduit approach or a lateral tunnel approach. The extracardiac Fontan uses an external conduit to anastomose the inferior vena cava into the pulmonary arteries, whereas a lateral tunnel Fontan uses a baffle within the right atrium (Figure 1). Because the systemic venous pathway is completely separated from the right atrium with the extracardiac Fontan, it is more challenging for the electrophysiologist to access the heart for ablation. My aim is to demonstrate why "the extracardiac conduit is the preferred Fontan approach for patients with univentricular hearts."The extracardiac Fontan has several advantages over the lateral tunnel Fontan. Advantage 1: Reduced Cardiopulmonary Bypass and Ischemic TimesMinimizing cardiopulmonary bypass and ischemia may optimize early postoperative outcomes. In multiple studies, both prolonged cardioplegic arrest and extended cardiopulmonary bypass times have been associated with an increased risk of early postoperative death or Fontan failure. [2][3][4] The technique of Fontan construction often dictates whether cardiopulmonary bypass or a period of ischemic arrest are required. With the lateral tunnel Fontan, the right atrium is opened for creation of the inferior vena cava baffle, necessitating the use of cardiopulmonary bypass. In addition, a period of cardioplegic arrest is required to stop the heart to prevent air embolic events until the atrium is closed. With the extracardiac Fontan, the right atrium is not opened. Vascular control is achieved at the right atrial-inferior vena cava junction. The inferior vena cava is transected and sewn to the extracardiac conduit, and the cardiac opening is oversewn. Vascular control of the pulmonary arteries is then achieved, and the conduit is sewn to the right pulmonary artery. Last, side-biting clamps are placed on the right atrium and conduit to create a fenestration if desired. With the use of this

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“…[51][52][53] The largest studies comparing thromboembolic events found no differences between intracardiac lateral tunnel and extracardiac Fontans, irrespective of the anticoagulant or antiplatelet treatment strategy. 25 …”

Section: Thromboembolismmentioning

confidence: 99%

“…Studies have consistently shown that postoperative Fontan pressures and transpulmonary gradients are similar with the 2 types of total cavopulmonary connections and that identical functional parameters are obtained on follow-up. 21,24,25 …”

Section: Hemodynamics and Functional Statusmentioning

confidence: 99%

“…Not surprisingly, cohort studies comparing intracardiac lateral tunnel with extracardiac Fontans have reported similar operative morbidity and mortality and midterm survival ( Figure 2B). [21][22][23][24][25][26] Thus, in contrast to anatomic considerations such as ventricular morphology and function, 14 total anomalous pulmonary venous return, 27,28 and heterotaxy syndromes, 27,29 the type of Fontan surgery has not convincingly been associated with long-term survival.…”

Section: Reality Overall Survivalmentioning

confidence: 99%

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