Clinical Results of the Staged Fontan Procedure in High-Risk Patients

• Published in: The Annals of thoracic surgery Vol. 65; no. 6; pp. 1721 - 1725
• Main Authors: Masuda, Munetaka, Kado, Hideaki, Shiokawa, Yuichi, Fukae, Kouji, Suzuki, Masao, Murakami, Eiji, Yasui, Hisataka
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier Inc 01.06.1998
• Subjects: Adolescent; Age Factors; Arteriovenous Shunt, Surgical; Blood Pressure; Cardiopulmonary Bypass; Child; Child, Preschool; Diastole; Follow-Up Studies; Fontan Procedure - methods; Humans; Infant; Palliative Care; Pulmonary Artery - pathology; Pulmonary Artery - surgery; Pulmonary Veins - abnormalities; Risk Factors; Tricuspid Valve Insufficiency - physiopathology; Vascular Resistance; Vena Cava, Superior - surgery; Ventricular Function - physiology; Ventricular Pressure
• DOI: 10.1016/S0003-4975(98)00264-1
• ISSN: 0003-4975

Background. For high-risk Fontan candidates, the introduction of a bidirectional Glenn shunt before total cavopulmonary connection (a two-staged strategy) may extend the indications for the Fontan procedure. The clinical results of the two-staged and one-staged Fontan procedure were thus reviewed and compared. Methods. Between November 1991 and July 1996, the two-staged strategy was performed in 40 high-risk Fontan candidates with a mean interval of 17.2 months after introducing the bidirectional Glenn shunt (staged group). We considered a young age (<2 years), high mean pulmonary arterial pressure (≥20 mm Hg), high pulmonary vascular resistance (≥3 Wood units), small pulmonary artery (Nakata index <200 mm 2/m 2), atrioventricular valve incompetence (≥ moderate), distortion of pulmonary artery, anomalous pulmonary venous return, and poor ventricular function as risk factors for the successful completion of Fontan circulation. During the same pe-riod, 68 patients underwent the modified Fontan procedure in a one-step fashion (primary group). Results. In the staged group after the bidirectional Glenn shunt, the mean pulmonary arterial pressure and ventricular end-diastolic pressure were both found to have decreased significantly to the same level as those in the primary group, whereas the pulmonary artery demonstrated a significantly smaller size than that in the primary group. Operative morbidity was similar in both groups. Operative mortality was also similar and low in both groups (1.5% in the primary group and 0% in the staged group). Conclusions. A bidirectional Glenn shunt was found to be a useful interim palliation in high-risk Fontan candidates. This two-staged strategy may extend the operative indications for the Fontan procedure.