Intra- or extracardiac Fontan operation? A simple strategy when to do what

Area of Science:

• Pediatric Cardiology
• Congenital Heart Surgery
• Cardiovascular Physiology

Background:

• The Fontan circulation is a critical palliative procedure for complex congenital heart disease.
• Two main techniques exist for Fontan completion after bi-directional Glenn anastomosis (BDG): intracardiac tunneling and extracardiac prosthesis.
• The optimal choice between these techniques remains a subject of ongoing debate in surgical practice.

Purpose of the Study:

• To retrospectively compare the outcomes of intracardiac versus extracardiac Fontan palliation in patients with single ventricle physiology.
• To identify factors influencing the choice of technique and their impact on postoperative recovery.
• To evaluate the feasibility and early results of both Fontan completion strategies.

Main Methods:

• Retrospective review of surgical and clinical records of 72 patients undergoing Fontan palliation post-BDG.
• Categorization of patients into intracardiac (group I) and extracardiac (group II) repair groups.
• Analysis of intraoperative variables (e.g., cardiopulmonary bypass time) and postoperative support (ventilatory, inotropic).

Main Results:

• Intracardiac tunneling (38 patients) was associated with significantly longer cardiopulmonary bypass (170 min vs. 104 min), ventilatory support (39 h vs. 21 h), and inotropic support (48 h vs. 10 h) compared to extracardiac repair (34 patients).
• Postoperative support duration was dependent on cardiopulmonary bypass and aortic cross-clamping times, particularly in the intracardiac group.
• No perioperative mortality was observed in either group, indicating the feasibility of both techniques.

Conclusions:

• Both intracardiac and extracardiac Fontan completion techniques are viable, with no perioperative mortality.
• Elective extracardiac repair is suitable for well-developed children with good hemodynamics post-BDG.
• Intracardiac baffle repair with fenestration is indicated for higher-risk patients (developmental delay, cyanosis, myocardial dysfunction, AV valve insufficiency), though prolonged bypass times require further mitigation strategies.