Importance of acquired systemic-to-pulmonary collaterals in the Fontan operation
K R Kanter1, R N Vincent, A A Raviele
1Division of Cardio-Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia 30322, USA. kkanter@emory.org
Insights
Systemic-to-pulmonary collateral arteries in children undergoing the Fontan procedure can cause complications. Aggressive occlusion of these vessels pre- and post-procedure improves survival rates in Fontan candidates.
Area of Science:
- Cardiology
- Pediatric Cardiac Surgery
- Vascular Biology
Background:
- Children with cyanotic heart disease often develop collateral arteries.
- These collateral arteries can lead to excessive pulmonary blood flow during the Fontan procedure, posing risks.
Purpose of the Study:
- To evaluate the impact of collateral vessel occlusion on outcomes in children undergoing the Fontan procedure.
- To assess the role of collaterals as a predictor of long-term cardiac failure.
Main Methods:
- A retrospective review of 93 children (aged 1.5-15.8 years) who underwent a fenestrated lateral tunnel Fontan procedure between June 1993 and May 1998.
- Collateral vessels were occluded preoperatively in 35% of patients and postoperatively in 20% for various complications.
Main Results:
- Operative survival was 97%, with 2 perioperative deaths attributed to excessive pulmonary blood flow from collaterals.
- Postoperative occlusion was associated with longer intensive care unit stays and hospitalizations.
- Eight patients with ventricular failure required significant collateral occlusion postoperatively.
Conclusions:
- Hemodynamically significant collaterals are frequent in Fontan candidates and require aggressive management.
- Postoperative collaterals may indicate a higher risk of future cardiac failure, with 8 of 18 patients requiring coils later dying or undergoing transplantation.
Background:
Children with chronic cyanotic heart disease often develop systemic-to-pulmonary collateral arteries that can be deleterious at the time of a Fontan procedure due to excessive pulmonary blood flow. We therefore occlude all significant collaterals during cardiac catheterization.
Methods:
From June 1993 to May 1998, 93 children aged 1.5 to 15.8 years (median 2.5 years) underwent a fenestrated lateral tunnel Fontan procedure. Eighty-nine (96%) had a previous bidirectional Glenn anastomosis, including 31 (33%) with a Norwood procedure.
Results:
Preoperatively, 33 children (35%) required occlusion of 1 to 11 (mean 3.6) collateral vessels. Two of the three perioperative deaths (operative survival 97%) were due to excessive pulmonary blood flow from unrecognized collaterals in one and uncontrollable collaterals in the other. Postoperatively, 19 children (20%) required coil occlusion of 1 to 21 (mean 5.6) collaterals for elevated pulmonary artery pressures, heart failure, or prolonged chest tube drainage. Duration of inotropic support, postoperative ventilation, intensive care unit stay, and postoperative hospitalization were all significantly longer in the patients who had postoperative occlusion of collaterals. On follow-up of 2 to 67 months (mean 35 months), there have been four late deaths (two infections, two heart failures); 6 patients underwent successful cardiac transplantation for refractory heart failure. All 8 patients with ventricular failure required occlusion of significant collaterals postoperatively.
Conclusions:
Hemodynamically significant collaterals are not uncommon in Fontan candidates, and aggressive control can result in good operative and medium-term survival. After the Fontan, significant collaterals may be a marker for eventual cardiac failure because 8 of 18 patients requiring postoperative coils went on to transplantation or died of heart failure.
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