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The fenestrated Fontan procedure
1Department of Cardiology, Children's Hospital, Boston.
Insights
Fenestration in the atrial baffle during Fontan repair improved outcomes for high-risk patients. This strategy reduced mortality and morbidity, leading to better functional status post-surgery.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Disease Surgery
- Cardiac Physiology
Background:
- The Fontan operation is a palliative procedure for complex congenital heart disease.
- High-risk patients often face increased mortality and morbidity after Fontan repair.
- Conditions limiting pulmonary blood flow can compromise cardiac output and elevate right atrial pressure.
Purpose of the Study:
- To evaluate the efficacy of atrial baffle fenestration in high-risk Fontan patients.
- To assess the impact of fenestration on mortality, morbidity, and functional outcomes.
- To determine the safety and effectiveness of subsequent transcatheter fenestration closure.
Main Methods:
- A cohort of 90 high-risk patients undergoing Fontan repair had an atrial baffle fenestration created.
- Fenestration aimed to create a right-to-left shunt to maintain cardiac output and limit right atrial pressure.
- Follow-up included assessment of mortality, morbidity (pleural effusions), right atrial pressures, and functional status (New York Heart Association Class).
Main Results:
- Early mortality was 4% (4/90 patients), with 2 additional patients requiring conversion to bidirectional cavopulmonary anastomosis.
- Postoperative right atrial pressures were low (average 13 mm Hg).
- Prolonged pleural effusions occurred in 13% of patients. At short-term follow-up (average 13 months), 77% had fenestration closure, and 92% were in New York Heart Association Class I.
Conclusions:
- Atrial baffle fenestration followed by transcatheter closure significantly decreases mortality and morbidity in high-risk Fontan patients.
- This strategy leads to improved functional status in the short term.
- The favorable outcomes support the continued aggressive management of such high-risk patients using this approach.
Abstract:
In 90 patients with characteristics placing them at increased risk for a Fontan operation, a fenestration was created in the atrial baffle at the time of the Fontan repair. The rational was to allow a right to left shunt which would maintain cardiac output and limit right atrial pressure in the presence of conditions which limit pulmonary blood flow. Early mortality was 4/90 (4%), with an additional two patients having the Fontan repair taken down to a bidirectional cavopulmonary anastomosis. Postoperative right atrial pressures were low (average 13 mm Hg), as was the incidence of prolonged pleural effusions (13%). At short-term (average 13 months) follow-up, 77% of patients have had closure of the fenestration, and 92% are in New York Heart Association Class I. We conclude that baffle fenestration with subsequent transcatheter closure results in decreased mortality and morbidity among high risk patients undergoing a Fontan repair, and that the high functional level at short-term follow-up justifies continued aggressive management of such patients.