|
Back to 85th Annual Meeting
Back to Program Outline
32. The Extracardiac Conduit Fontan Operation Using Minimal Approach Extracorporeal Circulation: Short and Long Term Outcomes
Ed Petrossian, V. Mohan Reddy, Kathryn K. Collins, Casey B. Culbertson, Malcolm J. Macdonald, John J Lamberti, Olaf Reinhartz, Richard D. Mainwaring, Sunil P. Malhotra, Sam Suleman, Frank L. Hanley; Stanford, CA
Objective: Our approach to the extracardiac conduit Fontan (ECF) operation has evolved over time, with increasing emphasis on minimal use of extracorporeal circulation. We have moved from full bypass (full pump), to partial pump, to completely off pump. This study is designed to report our experience with the ECF operation and to evaluate the evolution in bypass technique on postoperative outcomes.
Methods: From 9/1992 to 8/2004, 256 patients, median age 4.5 yrs (range 1.4-43), underwent a primary ECF. Conduit size was 20 mm or larger in 180 patients (70%). Perioperative outcomes and hemodynamics were compared between patients who underwent a Full Pump (FPF; 108 patients; 42%) vs. Off Pump (OPF; 42 patients; 16%) Fontan. Comparisons were also made between patients in whom an oxygenator was used in the circuit (O2F; 151 patients; 59%) vs. those in whom an oxygenator was avoided (NoO2F; 105 patients; 41%). Late survival data was collected.
Results: 253 patients (99%) survived to hospital discharge. Perioperative freedom from death or Fontan takedown was 97% (249 patients). Aortic cross clamp was avoided in 243 patients (95%). Full bypass was avoided in 148 (77%) of the last 191 patients. Median chest tube duration was 8 days (range 2-91). Median hospital stay was 11 days (range 4-106). 3 patients (1.2%) required perioperative permanent pacemaker for newly diagnosed dysrhythmias; one patient had sinus node dysfunction, and 2 patients had postop complete heart block (one after VSD enlargement). 5 patients (2 %) were discharged home on antiarrhythmia medications for newly diagnosed supraventricular tachyarrhythmias. Intraoperative fenestration was performed in 48 patients (19%). Fenestration rate was significantly higher in FPF (37 patients; 34%) and O2F (39; 26%) patients compared to OPF (3; 7%) and NoO2F patients (9; 9%) respectively with p<0.001 for both.
Compared to OPF, FPF was associated with higher perioperative Fontan pressure (13.9±2.5 mm Hg vs. 12.0±2.2, p<0.001), higher common atrial pressure (5.5±1.9 vs. 4.8±1.5, p=0.037), and higher transpulmonary gradient (8.4±2.5 vs. 7.3±1.9, p=0.017). Similarly, patients in the O2F group had higher Fontan pressure (13.5±2.4 vs. 12.0±2.3, p<0.001), higher common atrial pressure (5.3±1.8 vs. 4.6±1.8, p=0.003), and higher transpulmonary gradient (8.3±2.2 vs. 7.5±2.1, p=0.013) compared to the NoO2 F group.
Late mortality and Fontan takedown occurred in 4 patients and 1 patient respectively. 10-year actuarial survival was 95%. 10-year freedom from mortality, takedown or transplantation was 91%.
Conclusion: The ECF operation coupled with minimal use of extracorporeal circulation is associated with improved perioperative hemodynamics, decreased need for fenestration, and minimal rhythm disturbance.
Back to 85th Annual Meeting
Back to Program Outline
|
