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ICVTS on-line discussion A Issues regarding unifocalization

King Faisal Specialist Hospital and Research Centre, 11211 Jeddah, Saudi Arabia

One-stage unifocalization followed by staged Fontan operation

eComment: We read with great interest the article entitled: One-stage unifocalization followed by staged Fontan operation [1].

First described by Choussat et al., the ‘Ten Commandments’ have become the basic criteria for patient selection undergoing the Fontan operation. Choussat listed ten criteria that should ideally be satisfied to minimize morbidity and mortality with the Fontan procedure. These 10 commandments have been adapted over the years and are summarized as: age above 4 years, normal ventricular function, adequate pulmonary artery size, no distortion of pulmonary arteries from prior shunt surgery, low pulmonary artery pressure (below 15 mmHg), low pulmonary vascular resistance, normal systemic venous drainage, no atrioventricular valve leak, normal heart rhythm and no right atrial enlargement [2].

The current protocol in patients who fall into the high risk groups is firstly to review all the data in detail. Full consideration is given as to whether there are any surgically (or interventionally) correctable lesions such as AV valve regurgitation amenable to repair or isolated stenoses or hypoplasia within the central pulmonary arteries [3].

The guidelines for the surgical management of this anomaly include that all MAPCAS should be clearly delineated by preoperative aortogram at least up to the level of the diaphragm, so chances of missing would be less. In protected PAs/MAPCAs (proximal stenosis), complete repair or RV to PA conduit or central shunt should be done according to total size of PAs. In hypoplastic or absent PAs with unprotected MAPCAs (<1 year), or protected MAPCAs (proximal stenosis), complete repair/RV to PA conduit/central shunt should be done according to the size of the total pulmonary vasculature. Hypoplastic/absent PAs with unprotected MAPCAs (more than 1 year) are the subsets among these complex anomalies where we have yet to determine the surgical procedure to be performed. In single stage unifocalization, the number of operations, hospitalization and cost are reduced. These patients have early normalization of cardiovascular physiology with good future growth of unifocalized neo pulmonary arteries [4].

The MAPCAs are to be handled in several ways:

1. End-to-side or side-to-side anastomosis to the native pulmonary artery
   
2. Side-to-side anastomosis to other MAPCAs
   
3. Beveled end-to-side anastomosis to a polytetrafluoroethylene tube
   
4. Ligation of adequately communicating MAPCAs to the native pulmonary arteries
   
5. Ligation of MAPCAs to areas of the lung receiving significant dual blood supply
   
6. Ligation of small MAPCAs supplying a single bronchopulmonary segment if unifocalization of that segment was too difficult.
   

Exposure of all of the major aortopulmonary collaterals by opening the posterior pericardium without entering the pleura and completion of the right-sided unifocalization before commencing bypass. To reduce the potential neurologic complications, the right-sided unifocalization usually is accomplished before cardiopulmonary bypass at normothermia. The leftsided collaterals are localized and looped, ready to be snared as soon as bypass is instituted. Transection of the ascending aorta and retracting it to provide easy access to the MAPCAs and then doing the operation is very helpful. It may be easier and much more comfortable to do this kind of procedure with all the MAPCAs on both sides of the descending thoracic aorta. Do not hesitate to transect the ascending aorta if you have to access centrally hypoplastic, stenotic native pulmonary arteries to enlarge them and not to have to work behind the aorta if it is awkward. However, transecting the aorta to expose the MAPCAs implies that bypass is needed, and that increases the ischemia time [5].

	References

Top References

 

1. Shinkawa T, Yamagishi M, Shuntoh K, Yaku H. One-stage unifocalization followed by staged Fontan operation. Interact CardioVasc Thorac Surg 2007; 6:416–418.[Abstract/Free Full Text]
2. Choussat A, Fontan F, Besse P, Vallot F, Chauve A, Bricaud H. Andersson RH, Shinebourne EA. Selection criteria for Fontan's procedure. editors Paediatric Cardiology1977;Edinburgh: Churchill Livingstone 559–566. In:.
3. Hosein RBM, Clarke AJB, McGuirk SP, Griselli M, Stumper O, De Giovanni JV, Barron DJ, Brawn WJ. Factors influencing early and late outcome following the Fontan procedure in the current era. The ‘Two Commandments’? Eur J Cardiothorac Surg 2007; 31:344–353.[Abstract/Free Full Text]
4. Murthy KS, Krishnanaik S, Coelho R, Punnoose A, Arumugam SB, Cherian KM. Median sternotomy single stage complete unifocalization for pulmonary atresia, major aorto-pulmonary collateral arteries and VSDearly experience. Eur J Cardiothorac Surg 1999; 16:21–25.[Abstract/Free Full Text]
5. Tchervenkov CI, Salasidis G, Cecere R, Béland MJ, Jutras L, Paquet M, Dobell ARC. One-stage midline unifocalization and complete repair in infancy versus multiple-stage unifocalization followed by repair for complex heart disease with major aortopulmonary collaterals. J Thorac Cardiovasc Surg 1997; 114:727–737.[Abstract/Free Full Text]

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