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Comparative assessment of Fontan operation in modifications of atriopulmonary and total cavopulmonary anastomoses
V P Podzolkov1, S B Zaets, M R Chiaureli
1Scientific Centre of Cardiovascular Surgery RAMS, Moscow, Russia.
Insights
Total cavopulmonary anastomosis shows lower early mortality and a better early recovery compared to atriopulmonary anastomosis. However, atriopulmonary anastomosis yields superior long-term functional outcomes in Fontan operations.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Congenital Heart Disease
Background:
- The Fontan operation is a palliative procedure for complex single-ventricle congenital heart defects.
- The choice between atriopulmonary (AP) and total cavopulmonary anastomosis (TCPC) remains a subject of debate.
- Optimizing surgical techniques is crucial for improving outcomes in Fontan patients.
Purpose of the Study:
- To compare the outcomes of atriopulmonary anastomosis versus total cavopulmonary anastomosis in Fontan operations.
- To evaluate early and late mortality, postoperative complications, and long-term functional status.
- To analyze hemodynamic performance during exercise in patients undergoing different Fontan techniques.
Main Methods:
- Retrospective analysis of 81 TCPC and 69 AP Fontan operations performed between 1983 and 1995.
- Follow-up study including clinical assessment, cardiac catheterization, and exercise testing in a subset of patients.
- Comparison of preoperative and postoperative hemodynamic indices, mortality rates, and functional class.
Main Results:
- TCPC demonstrated lower early mortality (15% vs. 23%) and reduced early postoperative complications like circulatory insufficiency and pleural effusions.
- Late mortality was lower after TCPC (6% vs. 12%), with similar functional status (NYHA classes I-II) in both groups long-term.
- While physical tolerance improved in both groups, atriopulmonary anastomosis showed superior hemodynamic indices during exercise in the long term.
Conclusions:
- Total cavopulmonary anastomosis offers advantages in terms of reduced early mortality and a smoother early postoperative course.
- Atriopulmonary anastomosis, despite higher early risks, may lead to better long-term functional and hemodynamic results.
- The choice of technique should consider the balance between early surgical risks and long-term functional benefits.
Objectives:
The optimal technique of the Fontan operation remains disputable. This investigation was aimed at the comparison of atriopulmonary and total cavopulmonary anastomoses.
Methods:
The results of 81 operations of total cavopulmonary and 69 operations of atriopulmonary anastomosis, performed from 1983 to 1995 were analysed. A control study was carried out 1-10 (3.7 + 0.2) years after the operation in 80 patients (36 after total cavopulmonary and 44 after atriopulmonary anastomoses). 70 patients were studied several times. Cardiac catheterization was done in 70 patients. In 78 patients central hemodynamical indices were studied during exercise.
Results:
Preoperative hemodynamical indices were not reliably different in the two groups. Early mortality after total cavopulmonary anastomosis was 15%, after atriopulmonary anastomosis 23%. The highest mortality was seen when the criteria of Choussat et al. (Choussat et al. Pediatric Cardiology. Edinburgh: 1977:559-566) were surpassed. In the early postoperative period after total cavopulmonary anastomosis circulatory insufficiency was less marked, transsudation from pleural cavities was reliably lower (15.3 + 1.2 versus 25.5 + 1.8 ml/kg/day, P < 0.01). Arrhythmias were more common after total cavopulmonary anastomosis (18.5 versus 12%). Late mortality after total cavopulmonary anastomosis was 6%, after atriopulmonary anastomosis 12%. 82% of patients after atriopulmonary anastomosis and 81% after total cavopulmonary anastomosis were in NYHA classes 1 and 2.7% of patients after total cavopulmonary anastomosis and 11% after atriopulmonary anastomosis were reoperated. Physical tolerance rose stepwise in both groups and by the third post-operative year reached 75% of normal level. At this time we saw the most optimal hemodynamical indices during exercise. However, the best hemodynamics during exercise were seen after atriopulmonary anastomosis.
Conclusions:
Total cavopulmonary anastomosis is accompanied by lower mortality rate and a more favourable course of early postoperative period. However, the best long-term functional results are obtained after atriopulmonary anastomosis.