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Implantation of Total Artificial Heart in Congenital Heart Disease
Published on: July 18, 2014
Extracardiac conduit versus lateral tunnel cavopulmonary connections at a single institution: impact on outcomes
A Azakie1, B W McCrindle, G Van Arsdell
1Department of Surgery, Division of Cardiovascular Surgery, the Hospital for Sick Children, University of Toronto School of Medicine, Toronto, Ontario, Canada.
Insights
The extracardiac conduit (EC) technique for Fontan operations resulted in comparable outcomes to the lateral tunnel (LT) technique, despite higher preoperative risk in the EC group. EC Fontan surgery reduces early and midterm atrial arrhythmias.
Area of Science:
- Cardiology
- Pediatric Cardiology
- Congenital Heart Disease Surgery
Background:
- The Fontan operation is a palliative procedure for single-ventricle physiology.
- Extracardiac conduit (EC) and lateral tunnel (LT) are two common techniques for total cavopulmonary connection.
- Comparing outcomes between these techniques is crucial for optimizing surgical strategies.
Purpose of the Study:
- To compare the clinical outcomes of extracardiac conduit (EC) versus lateral tunnel (LT) Fontan connections.
- To identify potential differences in operative risk and postoperative complications between the two techniques.
Main Methods:
- A retrospective review of 107 patients undergoing total cavopulmonary connections between 1994 and 1998.
- Comparison of preoperative characteristics, operative data, and postoperative outcomes between the EC (n=60) and LT (n=47) groups.
- Analysis included mortality, arrhythmias, intensive care unit stay, and long-term survival.
Main Results:
- Operative mortality was similar (5.6%) between groups.
- The LT group had significantly higher rates of postoperative sinoatrial node dysfunction, supraventricular tachycardia, and need for pacing.
- The EC group experienced fewer early and intermediate atrial arrhythmias, with comparable long-term survival and ventricular function.
Conclusions:
- The extracardiac conduit technique is associated with a reduced risk of early and midterm atrial arrhythmias compared to the lateral tunnel technique.
- Despite higher preoperative risk factors in the EC group, outcomes were comparable, suggesting its safety and efficacy.
- EC Fontan surgery offers an advantage in mitigating arrhythmias postoperatively.
Objective:
To compare outcomes of extracardiac conduit and lateral tunnel Fontan connections in a single institution over a concurrent time period.
Methods:
Between January 1994 and September 1998, 60 extracardiac conduit and 47 lateral tunnel total cavopulmonary connections were performed. Age, sex, and weight did not differ between the 2 groups. Compared with the lateral tunnel group (LT group), patients undergoing the extracardiac conduit procedure (EC group) had a trend to a higher incidence of morphologically right ventricle (EC group 48% vs LT group 32%; P <.09), a higher incidence of isomerism/heterotaxy syndrome (EC 22% vs LT 0%; P <.001), worse atrioventricular valve regurgitation (EC 11% moderate-plus vs LT 0%; P <.06), and lower McGoon indices (EC 1.8 +/- 0.5 vs LT 2.1 +/- 0.5; P <.03). Preoperative arrhythmias, transpulmonary gradients, room air oxygen saturations, ejection fractions, ventricular end-diastolic pressure, and pulmonary artery distortion did not differ between groups. Cardiopulmonary bypass times and fenestration usage were similar in both groups.
Results:
Overall operative mortality was 5.6% and did not differ between groups. The LT group had a significantly higher incidence of postoperative sinoatrial node dysfunction (45% vs EC group 15%; P <.007), supraventricular tachycardia (33% vs EC group 8%; P <.0009), and need for temporary postoperative pacing (32% vs 12%; P <.01). Median duration of intensive care unit stay (EC 2 days, range 1-10 days, vs LT 2.8 days, range 1-103 days; P <.07) and ventilatory support (EC 1 day, range 0.25-10 days, vs LT 1 day, range 0.25-99 days; P <.03) were all longer in the LT group. Median chest tube drainage (EC 8 days, LT 9 days) was similar in both groups. Follow-up averaged 2.5 +/- 1.4 years in the EC group and 2.8 +/- 1.9 years in the LT group. There were 2 late deaths. Overall survival is 94% at 1 month, 92% at 1 year, and 92% at 5 years. Late ejection fraction or atrioventricular valve function did not differ between groups. Intermediate follow-up Holter analysis showed a higher incidence of atrial arrhythmias in the LT group (23% vs 7%; P <.02). Multivariable analysis showed that (1) prolonged cardiopulmonary bypass time was the only independent predictor for perioperative mortality, prolonged ventilation and intensive care unit length of stay, and increased time to final removal of chest tube drains and (2) lateral tunnel Fontan connection is an independent predictor of early postoperative and intermediate atrial arrhythmias.
Conclusions:
Although patients in the EC group were at higher preoperative risk, their outcomes were comparable with those of the LT group. Use of the extracardiac conduit technique for the modified Fontan operation reduces the risk of early and midterm atrial arrhythmia.
