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The influence of pulmonary artery banding on outcome after the Fontan operation
1Department of Pediatric Cardiology, Deutsches Herzzentrum München, Germany.
Insights
Pulmonary artery banding before the Fontan operation may increase ventricular mass, leading to a higher risk of complications. Long-standing banding should be avoided in Fontan candidates to improve outcomes.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Disease Surgery
- Cardiovascular Physiology
Background:
- The Fontan operation is a palliative procedure for complex congenital heart disease.
- Pulmonary artery banding (PAB) is sometimes used as a staged palliation before the Fontan procedure.
- The long-term effects of PAB on ventricular remodeling and subsequent Fontan outcomes are not fully understood.
Purpose of the Study:
- To compare clinical and hemodynamic parameters in patients undergoing the Fontan operation with prior pulmonary artery banding versus those with native pulmonary stenosis.
- To identify preoperative factors associated with postoperative complications after the Fontan operation.
- To evaluate the impact of long-standing pulmonary artery banding on Fontan outcomes.
Main Methods:
- Retrospective analysis of 38 patients who underwent the Fontan operation.
- Classification into two groups: Group 1 (previous PAB) and Group 2 (native pulmonary stenosis).
- Preoperative assessment included cardiac catheterization and cineangiocardiography; postoperative assessment evaluated effusions, ascites, organ dysfunction, and clinical status.
Main Results:
- Group 1 showed a significantly higher ventricular mass index (125.8 gm/m2 vs. 87 gm/m2) compared to Group 2.
- Severe early postoperative pericardial effusions were more frequent in Group 1 (p < 0.01).
- Subaortic stenosis was also more common in Group 1.
Conclusions:
- Significant ventricular mass increase after pulmonary artery banding may indicate a risk for unfavorable Fontan outcomes.
- Long-standing pulmonary artery banding as a palliative measure for Fontan candidates should be avoided.
- Careful consideration of prior palliative procedures is crucial for optimizing Fontan operation results.
Abstract:
Thirty-eight patients were selected from a total of 120 patients who underwent the Fontan operation between 1974 and 1988. They were classified into two groups. Group 1 consisted of 18 patients with previous pulmonary artery banding at a mean age of 7 months (2 days to 59 months), and group 2 comprised 20 patients with native pulmonary stenosis. In group 1, 10 children had tricuspid atresia (seven with normally connected and three with transposed great arteries), six had double-inlet ventricle, and two had complex heart malformations. Group 2 consisted of 12 patients with tricuspid atresia and normally connected great arteries, six with double-inlet ventricle, and two with complex malformations. The following clinical and hemodynamic parameters at cardiac catheterization and cineangiocardiography were determined in both groups before the Fontan operation: age and body surface area, hemoglobin concentration and hematocrit value, atrial and pulmonary artery pressures, end-diastolic pressure of the systemic ventricle, arterial oxygen saturation, pulmonary/systemic flow ratio, end-diastolic volume, ejection fraction and mass of the systemic ventricle, cardiac index, and Nakata index. After the Fontan operation in all patients, the presence or absence of pericardial and pleural effusions, ascites, protein-losing enteropathy, and liver and kidney dysfunction was assessed and the clinical status was classified according to New York Heart Association criteria. All preoperative and postoperative parameters were tested for differences between the two groups, and they were compared with normal values. Hematocrit value was higher in group 2 than in group 1 (57.8% versus 53.1%; p less than 0.05). Ventricular mass index was increased in group 1 when compared with group 2 (125.8 gm/m2 versus 87 gm/m2; p less than 0.05). Severe pericardial effusions in the early postoperative period were significantly more frequent in group 1 and were particularly prevalent in the subgroup with long-standing pulmonary artery banding (p less than 0.01). Subaortic stenosis was observed more frequently in group 1. The remaining parameters were not statistically different between the two groups. We conclude that the significant increment in ventricular mass after pulmonary artery banding may represent a risk for unfavorable outcome after the Fontan operation, which increases with time. Therefore, long-standing pulmonary artery banding as a palliative procedure for candidates for the Fontan operation should be avoided.