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Pulmonary atresia with intact ventricular septum: results of the Fontan procedure
H K Najm1, W G Williams, J G Coles
1Department of Surgery, Hospital for Sick Children, Toronto, Ontario, Canada.
Insights
The Fontan operation offers satisfactory outcomes for children with pulmonary atresia and intact ventricular septum. Specific surgical approaches, like right ventricle thromboexclusion, depend on coronary artery connections to optimize survival rates.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Disease Surgery
Background:
- Pulmonary atresia with an intact ventricular septum presents a spectrum of cardiac anomalies.
- Surgical repair options vary, including biventricular repair, Fontan procedure, or a one-and-a-half ventricle repair.
- Right ventricle-to-coronary artery connections, especially with right ventricle-dependent coronary artery blood flow, represent a high-risk subgroup.
Purpose of the Study:
- To evaluate the outcomes of the Fontan operation in children with pulmonary atresia and an intact ventricular septum.
- To assess the impact of right ventricle-to-coronary artery connections and right ventricle-dependent coronary artery blood flow on surgical results.
- To determine the indications for right ventricle thromboexclusion in this patient population.
Main Methods:
- A cohort of 22 children with pulmonary atresia and intact ventricular septum underwent the Fontan operation between 1980 and 1994.
- Patients had a mean age of 5.8 years and had undergone prior palliative procedures.
- Right ventricle-to-coronary artery connections were present in 15 patients; 5 had right ventricle-dependent coronary artery blood flow. Thromboexclusion was performed in 10 patients.
Main Results:
- The study reported three early deaths (13.6%) and one late death, with a 10-year actuarial survival of 80%.
- Early postoperative complications occurred in 4 children. Follow-up averaged 4 years.
- Atrial arrhythmia affected 3 children, and 4 required permanent pacemakers.
Conclusions:
- The Fontan operation yields satisfactory results for pulmonary atresia with an intact ventricular septum.
- Right ventricle thromboexclusion is recommended for right ventricle-to-coronary artery connections without right ventricle-dependent coronary artery blood flow.
- In cases of right ventricle-dependent coronary artery blood flow, the right ventricle should not be decompressed or thromboexcluded; saturated blood must enter the right ventricle during the Fontan operation.
Background:
Children with pulmonary atresia and an intact ventricular septum show a heterogeneous spectrum of cardiac anomalies. A biventricular repair is attainable in some; a Fontan procedure or a one-and-a-half ventricle is the only possible repair for others. Children with right ventricle-to-coronary artery connections, with or without right ventricle-dependent coronary artery blood flow, are a high-risk group.
Methods:
Between May 1980 and December 1994, 22 children underwent a Fontan operation for the treatment of pulmonary atresia with an intact ventricular septum at The Hospital for Sick Children, Toronto. The mean age was 5.8 years (median, 4.9 years). All children had had at least one pre-Fontan palliative procedure; 19 had two, and 7 of these had three or more. Right ventricle-to-coronary artery connections were present in 15 children, including 5 with right ventricle-dependent coronary artery blood flow. Thromboexclusion of the right ventricle was done in 10 children, with 7 undergoing it before and 3 at the time of the Fontan procedure.
Results:
There were three early deaths (13.6%) and one late death. The actuarial survival at 10 years after the Fontan operation was 80%. Early postoperative complications occurred in 4 children. Follow-up was completed in all children at a mean of 4 years (range, 1 to 12.5 years) after the Fontan operation. Atrial arrhythmia occurred in 3 children, and permanent pacemakers were required in 4.
Conclusions:
Results of the Fontan operation for the treatment of pulmonary atresia with an intact ventricular septum are satisfactory. Thromboexclusion of the right ventricle is indicated in the presence of right ventricle-to-coronary artery connections without right ventricle-dependent coronary artery blood flow. The right ventricle should not be decompressed or thromboexcluded in children with right ventricle-dependent coronary artery blood flow, and at the Fontan operation, saturated blood must enter the right ventricle.