Total Cavopulmonary Anastomosis: Selection Criteria Related to Postoperative Results

Abstract

In this study we review our experience with total cavopulmonary anastomosis (modified Fontan procedure) which was performed in 31 patients. One patient died from postoperative cardiac low-output syndrome, the other died from a neurological complication (early mortality 6.5%). During a mean follow-up period of 15 months there was no late mortality. Preoperative assessment showed that one, two, or three of the Choussat criteria (defining the ideal Fontan candidate) were not fulfilled by 39%, 16% and 6% of our patients. In the 2 patients who died 2 and 3 of those criteria were not fulfilled. Poor outcome could not be predicted based on assessment of the pulmonary artery size (expressed as the McGoon-ratio or the Nakata-index) alone. In order to assess the relationship of pulmonary artery size and pulmonary arteriolar resistance (PVR) as a predictor of outcome, we introduced two new indices (McGoon-ratio/PVR and Nakata-index/PVR). The patient who died from poor postoperative hemodynamics had the lowest values of all patients. Among the 29 survivors we did not observe significant acquired postoperative arrhythmias. In our experience the total cavopulmonary anastomosis can be performed with a low mortality and good postoperative results. Patients who do not fulfill at least 8 of the Choussat criteria and children with a low ratio of pulmonary artery size to PVR are high-risk patients. In these children we recommend either a bidirectional Glenn anastomosis as a first-step procedure or a total cavopulmonary anastomosis with a fenestration of the intraatrial tunnel.

Surgical Palliation of Severe Tricuspid Valve Stenosis in a Dog by Use of Fontan's Procedure

“…Since then, many changes in this technique have been made, including direct anastamosis of the right atrial appendage or vena cava to the pulmonary artery to eliminate the use of synthetic material 12 . Careful selection of candidates for the Fontan procedure is essential and depends on several criteria 13,14 . The most important criteria are the ability of the right atrium to generate sufficient pressure to pump blood from that chamber through a conduit to the pulmonary artery, and the absence of pulmonary hypertension.…”

“…Complications include low cardiac output syndrome, arrhythmias, right atrial dilation, atrial thrombi, thromboembolism, coagulation disorders, peripheral edema, liver dysfunction, and protein losing enteropathy 13,15–20 . Mortality rates after Fontan operations in humans vary between reported series; Mair et al report a pre‐1980 mortality of 17%, which, since 1980, has dropped to 8% 21 ; Hofbeck reported a mortality of 6.5% in a series of modified Fontan operations 13 . Because of the significant incidence of complications, some authors consider the Fontan procedure to be palliative rather than curative 14,22 …”

Spätpostoperative Herzrhythmusstörungen nach totaler cavopulmonaler Anastomose und ihre Beziehung zum Operationsalter der Patienten

“…Pausen mit einer Dauer von über 2 Sekunden bestanden bei keinem der jüngeren und bei 5 der älteren Kinder (p = 0,04). Eine spezifische Therapie wegen Problemen der Sinusknotenfunktion wurde bei keinem der jüngeren (4,(17)(18)(19)33). Wir haben in unserem Kollektiv die Frage untersucht, ob ein früherer Operationstermin auch einen Einfluss hat auf die Häufigkeit spätpostoperativer Dysrhythmien.…”