Total cavopulmonary direct anastomosis in the beating heart without prosthetic material: preliminary experience with modified extracardiac fontan procedure

To describe modified extracardiac Fontan procedure characterized with total cavopulmonary direct anastomosis in the beating heart without using prosthetic material in seven patients and summarize the clinical experiences and follow-up results.

From April 2007 to April 2011, seven patients with complex cardiac anomalies underwent this operation. The main pulmonary artery (MPA) was transected at the base of the pulmonary valve and the pulmonary annulus was oversewn. Then the inferior vena cava (ICV) was transected at the junction with the atrium. The MPA was brought to the side of the ICV and anastomosed in an end-to-end fashion. The superior vena cava (SVC) was transected at its entrance into the right atrium and was anastomosed to the right pulmonary artery. Five patients received transcatheter device closure of the fenestration with either a small atrial septal defect or ventricular septal defect occluder.

All patients were in sinus rhythm and extubated on the first postoperative day. Immediate postoperative arterial oxygen saturation was 95% (93% to 96%). During the follow-up period from 17 to 65 months (median 48 months), there were no deaths and reoperations. Arterial oxygen saturation ranged from 88% to 92% on room air. The fenestration was closed in five patients postoperatively and the arterial oxygen saturation rose to 95%.

Total cavopulmonary direct anastomosis in the beating heart without the use of prosthetic material provides growth potential, and avoids the need for anticoagulation. Longer follow-up will be necessary to evaluate this modification.