Original Articles
Clinical Results of the Staged Fontan Procedure in High-Risk Patients

https://doi.org/10.1016/S0003-4975(98)00264-1Get rights and content

Abstract

Background. For high-risk Fontan candidates, the introduction of a bidirectional Glenn shunt before total cavopulmonary connection (a two-staged strategy) may extend the indications for the Fontan procedure. The clinical results of the two-staged and one-staged Fontan procedure were thus reviewed and compared.

Methods. Between November 1991 and July 1996, the two-staged strategy was performed in 40 high-risk Fontan candidates with a mean interval of 17.2 months after introducing the bidirectional Glenn shunt (staged group). We considered a young age (<2 years), high mean pulmonary arterial pressure (≥20 mm Hg), high pulmonary vascular resistance (≥3 Wood units), small pulmonary artery (Nakata index <200 mm2/m2), atrioventricular valve incompetence (≥ moderate), distortion of pulmonary artery, anomalous pulmonary venous return, and poor ventricular function as risk factors for the successful completion of Fontan circulation. During the same pe-riod, 68 patients underwent the modified Fontan procedure in a one-step fashion (primary group).

Results. In the staged group after the bidirectional Glenn shunt, the mean pulmonary arterial pressure and ventricular end-diastolic pressure were both found to have decreased significantly to the same level as those in the primary group, whereas the pulmonary artery demonstrated a significantly smaller size than that in the primary group. Operative morbidity was similar in both groups. Operative mortality was also similar and low in both groups (1.5% in the primary group and 0% in the staged group).

Conclusions. A bidirectional Glenn shunt was found to be a useful interim palliation in high-risk Fontan candidates. This two-staged strategy may extend the operative indications for the Fontan procedure.

Section snippets

Patients and methods

A total of 108 patients underwent a modified Fontan procedure, total cavopulmonary connection, at Fukuoka Children’s Hospital between November 1991 and July 1996. In 68 patients a primary Fontan operation was done in a single stage fashion (primary group). In 40 patients a preliminary bidirectional Glenn shunt was first performed before the completion of the Fontan operation (staged group). The selection of the operative strategy in these patients mainly depended on the preoperative risk

Results

The myocardial ischemic time was significantly shorter in the staged group (41.1 ± 26.4 minutes) than in the primary group (57.1 ± 23.5 minutes), partially because of the frequent application of an extracardiac conduit in the staged group. The cardiopulmonary bypass time was also significantly shorter in the staged group (136.6 ± 42.6 minutes) than in the primary group (165.5 ± 54.3 minutes) because the bidirectional Glenn shunt had already been made in this group in addition to the shorter

Comment

The Fontan operation is a definitive palliation for complex cardiac anomalies with a functional single ventricle. In addition to completing the Fontan procedure, concomitant procedures such as plasty of the atrioventricular valve, plasty of the pulmonary artery, and the repair of anomalous pulmonary venous drainage are frequently required in such high-risk patients. Prolonged cardiopulmonary bypass time and myocardial ischemic time may increase the operative mortality and morbidity of these

Acknowledgements

We express our gratitude to Dr Shigeki Morita (Division of Cardiac Surgery, Kyushu University) and Brian Quinn (English Medical Editor, Kyushu University) for comments on the manuscript.

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