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Outcomes of the Fontan procedure using cardiopulmonary bypass with aortic cross-clamping
David B Meyer1, Guillermo Zamora, Gil Wernovsky
1Department of Cardiothoracic Surgery, New York University, New York, New York, USA.
Insights
The Fontan procedure using cardiopulmonary bypass (CPB) and aortic cross-clamping is safe, showing low mortality and morbidity. This approach, despite concerns, yields good outcomes in complex pediatric heart surgeries.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Surgery
- Cardiovascular Surgery
Background:
- The Fontan procedure is a palliative surgery for complex single-ventricle congenital heart defects.
- Concerns exist regarding the use of cardiopulmonary bypass (CPB) and aortic cross-clamping in the Fontan procedure.
- This study evaluates outcomes when CPB and aortic cross-clamping are utilized.
Purpose of the Study:
- To assess the safety and outcomes of the Fontan procedure performed with cardiopulmonary bypass (CPB) and aortic cross-clamping.
- To identify risk factors associated with prolonged pleural drainage and hospitalization.
Main Methods:
- Retrospective review of 160 patients undergoing the Fontan procedure between 2000 and 2004.
- Analysis of CPB, aortic cross-clamping, deep hypothermic circulatory arrest (DHCA), and surgical techniques (lateral tunnel vs. extracardiac).
- Multivariable analysis to determine risk factors for adverse outcomes.
Main Results:
- Low mortality (2/160) and high freedom from death or takedown (98%).
- Extracardiac connection and elevated pre-Fontan pulmonary artery pressure were linked to longer pleural drainage.
- Extracardiac connection, longer CPB/DHCA duration, and lower pre-Fontan oxygen saturation correlated with extended hospitalization.
Conclusions:
- The Fontan procedure can be safely performed using CPB and aortic cross-clamping.
- This approach is associated with low morbidity and mortality.
- Risk factors for prolonged drainage and hospitalization were identified, aiding in risk stratification.
Background:
Avoidance of cardiopulmonary bypass (CPB) and aortic cross-clamping during the Fontan procedure has been advocated to improve outcomes. We continue to use CPB with aortic cross-clamping for the Fontan procedure.
Methods:
We performed a review of patients undergoing the Fontan procedure between January 1, 2000 and December 31, 2004.
Results:
The Fontan procedure was performed in 160 patients. The median age was 2.2 years (range, 1.0 to 29.1 years). Hypoplastic left heart syndrome or a variant was present in 114 patients (71%), and heterotaxy was present in 19 (12%). CPB and modified ultrafiltration were used in all patients. Aortic cross-clamping was used in 154 (96%) of 160 patients and deep hypothermic circulatory arrest (DHCA) in 132 (83%). A lateral tunnel Fontan was performed in 69 patients (43%) and an extracardiac Fontan in 91 (57%). A fenestration was created in 144 patients (90%). Two patients died. Freedom from death or takedown was 98% (157/160). Median duration of pleural drainage was 2 days (range, 1 to 44 days) and was more than 14 days in 16 patients. Median duration of hospitalization was 6 days (range, 3 to 55 days). The small number of deaths precluded assessment of risk factors for mortality. By multivariable analysis, risk factors for pleural drainage longer than 3 days were extracardiac connection (p < 0.001) and increasing mean pulmonary artery pressure before the Fontan procedure (p = 0.033). By multivariable analysis, risk factors for hospitalization for more than 7 days were extracardiac connection (p = 0.003), increasing duration of total support (CPB and DHCA, p = 0.027), and decreasing systemic oxygen saturation before the Fontan procedure (p = 0.048).
Conclusions:
The Fontan procedure can be performed using CPB and aortic cross-clamping with low morbidity and mortality.
