Interactive Cardiovascular and Thoracic Surgery 2:379-381(2003)
© 2003 European Association of Cardio-Thoracic Surgery
A new approach to hemi-Fontan type of operation
Viktor Hraska*
Department of Cardiac Surgery, Children's University Hospital, Limbova 1, 833 40 Bratislava, Slovakia
* Present address. University Hospital Eppendorf-Hamburg, Martinistrase 52, D-20246 Hamburg, Germany
v.hraska{at}uke.uni-hamburg.de
Received October 3, 2002;
received in revised form May 7, 2003;
accepted May 12, 2003
 |
Abstract
|
|---|
A new technique for hemi-Fontan procedure for single ventricle type of physiology is suggested. In addition to the standard bidirectional cavopulmonary anastomosis, this approach includes creation of a blind anastomosis between the opened roof of the right atrium and right pulmonary artery. This new technique simplifies completion of the lateral tunnel Fontan procedure.
Key Words: Single ventricle; Cavopulmonary anastomosis; Hemi-Fontan
|
1. Introduction
|
|---|
Significant improvement in late outcomes after the Fontan procedure has been accomplished by staged reconstruction of single-ventricle physiology [1]. The cavopulmonary shunt, either bidirectional Glenn or hemi-Fontan procedure, is considered as a preparatory stage which should minimize the risk factors for a Fontan-type of circulation. A new technique for hemi-Fontan procedure, which has a potential to simplify the Fontan connection, is described.
|
2. Technique
|
|---|
The hemi-Fontan procedure is performed through median sternotomy using cardiopulmonary bypass. The superior vena cava (SVC) is dissected free and the azygos vein is transected. During cooling, the pulmonary artery (PA) is extensively dissected free and mobilized. The SVC is occluded with vascular clamps. The SVC is transected above the distal clamp and a longitudinal pulmonary arteriotomy is created along the superior margin of the right PA. A standard cavopulmonary anastomosis is accomplished with running 7-0 monofilament suture. At a rectal temperature of 30°C the heart is fibrillated, the IVC is looped with tourniquet, and distal clamp on SVC is released. An incision is made in the medial aspect of the stump of SVC and carried horizontally well beyond the junction of SVC and right atrium (RA), opening the roof of RA (Fig. 1). The opened roof of the RA, including the stump of SVC, is anastomosed in end-to-side fashion to the inferior wall of the central and right PA, creating the blind connection (Fig. 2). The wall of PA separates PA from the RA. At this point the heart is defibrillated and re-warming is begun.
View larger version (96K):
[in this window]
[in a new window]
|
Fig. 1 Bidirectional cavopulmonary anastomosis is centrally located. Incision of medial aspect of cardiac end of superior vena cava is carried horizontally well beyond the junction of superior vena cava and right atrium.
|
|
View larger version (99K):
[in this window]
[in a new window]
|
Fig. 2 The opened roof of the right atrium, including the stump of superior vena cava, is anastomosed in end-to-side fashion to the inferior wall pulmonary artery, creating the blind connection.
|
|
The third stage, completion of Fontan procedure, is undertaken using bi-caval cannulation and hypothermic cardiopulmonary bypass. After the patient is cooled to 28°C, the aorta is cross-clamped and blood cardioplegia is administered into the root of the aorta. An incision in the free wall of the right atrium, parallel to the sulcus terminalis, is made. Another incision is made in the anterior wall of the right pulmonary artery, parallel to the cavopulmonary anastomosis. Working through both these exposures, the wall of pulmonary artery separating the PA and the right atrium is widely excised. Total caval pulmonary connection is accomplished by the lateral tunnel, using the polytetrafluoroethylene (PTFE) patch with 4 mm fenestration. After de-airing the heart, the cross-clamp is released and re-warming is begun. Before discontinuation of bypass, monitoring lines and wires are placed. After weaning from bypass modified ultra-filtration is performed.
|
3. Results
|
|---|
Between July 2001 and June 2002 this technique of hemi-Fontan procedure was used in 15 infants with single ventricle type of physiology. Median age at operation was 6.5 months. There was no early or late death, all patients are doing well with arterial saturation around 80%, and preserved sinus rhythm. One patient has undergone completion of Fontan procedure.
|
4. Comment
|
|---|
The cavopulmonary shunt, either bidirectional Glenn or hemi-Fontan, plays a crucial role in overall pre-Fontan management that is focused on elimination of risk factors of single ventricle type of circulation. Hemodynamically there is no significant difference between the bidirectional Glenn and hemi-Fontan type of cavopulmonary shunt [2]. The advantage of the hemi-Fontan approach is simplification of the subsequent Fontan procedure. Hemi-Fontan can be accomplished by creating anastomoses between both the cranial and cardiac ends of the SVC and the PA with the SVC-RA orifice occluded by a PTFE patch. An alternative approach is to create side to side anastomosis between the SVC and right PA, augmenting this confluence by homograft tissue and creating a bind pouch which closes the surgically enlarged junction of the RA with right PA [3]. The disadvantage of the first technique is the necessity to close the orifice of the SVC-RA by a patch with no growth potential, leading to problems with creation of sufficiently large cavopulmonary anastomosis at the time of definitive palliation. The second technique uses the homograft tissue for more complex reconstruction of SVC-PA-RA anastomosis.
A new technique of hemi-Fontan described herein does not use artificial material, native tissue to tissue blind anastomosis has growth potential and the technique is simple and easy to reproduce. Completion of the Fontan operation entails only wide excision of the wall of pulmonary artery separating the PA and the RA (blind anastomois – pulmonary dam) and creation of lateral tunnel with fenestration. During the completion of Fontan operation extensive dissection around the sinus node and mobilization of pulmonary artery is completely avoided. The risk of damaging the sinus node artery is not different in comparison with technique of total cavopulmonary anastomosis with lateral tunnel done as III. stage palliation. The longer follow-up and bigger cohort of patients are needed to make any firm conclusion about these issues.
|
Acknowledgements
|
|---|
I am grateful to Dominique Duval for the illustrations.
doi:10.1016/S1569-9293(03)00106-3
|
References
|
|---|
- Forbess JM, Cook N, Serraf A, Burke RP, Mayer JE Jr, Jonas RA. An institutional experience with second- and third-stage palliative procedures for hypoplastic left heart syndrome: the impact of the bidirectional cavopulmonary shunt. J Am Coll Cardiol. 1997;29:665–670[Abstract]
- Mainwaring RD, Lamberti JJ, Uzak K. The bidirectional Glenn procedure: palliation of the univentricular heart. Adv Card Surg. 1994;5:115–140[Medline]
- Jacobs ML, Rychik J, Rome JJ, Apostolopoulou S, Pizarro C, Murphy JD, Norwood WI Jr. Early reduction of the ventricular work of the single ventricle; the hemi-Fontan operation. Ann Thorac Surg. 1996;62:456–461[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
A. M. Gaca, J. J. Jaggers, L. T. Dudley, and G. S. Bisset III
Repair of Congenital Heart Disease: A Primer-Part 1
Radiology,
June 1, 2008;
247(3):
617 - 631.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
Top
Abstract
1. Introduction