Early Result of Fenestration on Total Cavopulmonary Connection_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

LIXia ¹ , LIShou-jun ² ,  WANGXu ¹ , YANJun ² , YANGJu-xian ¹ , ZENGMin ¹ , LISheng-li ¹ , DUANLei-lei ¹

1. Pediatric Intensive Care Unit, Pediatric Cardiac Center, Fu Wai Hospital, Beijing 100037, P. R. China;
2. Department of Surgery, Pediatric Cardiac Center, Fu Wai Hospital, Beijing 100037, P. R. China;

Corresponding author：

WANGXu, Email: fwpicu@sina.com

Keywords：

Congenital heart disease; Cardiac surgery; Total cavopulmonary connection; Fenestration

DOI：

10.7507/1007-4848.20150207

Video：

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Objective To investigate the effect of fenestration on total cavopulmonary connection (TCPC) in the treatment of complex congenital heart disease. Methods We retrospectively analyzed the clinical data of 142 patients undergoing TCPC in Fu Wai Hospital between January 2010 and December 2013. The patients were divided into 2 groups depending on with fenestration or not. There were 71 patients including 44 males and 27 females at age of 65.7+24.5 months in the fenestration group. There were also 71 patients with 42 males and 29 females at age of 60.7+20.8 months in the no fenestration group. Perioperative variables were compared between the two groups. Results Four patients (2.82%) died postoperatively. The fenestration significantly increased in the patients with atrioventricular valve regurgitation (AVVI). There were no statistical differences in duration of mechanical ventilation, ICU hospitalized time, early mortality and complications between the two groups (P>0.05). But there were statistical differences in the postoperative pleural effusion duration and 24 h capacity requirement (9.1 d versus 13.1 d, 4.19 ml/(kg · h) versus 5.48 ml/(kg · h)) between the two groups. In the patients whose preoperative mPAP was more than 12 mm Hg, postoperative CVP was lower (P=0.046), maintaining the same blood pressure (SBP=80-90 mm Hg) of vasoactive drugs (P=0.019) and 24 h capacity requirement (P=0.041) were lower, pleural effusion duration was shorter (9.8 d versus 17.8 d, P=0.000) in the fenestration children. 113 patients were followed up for 1.1+1.2 years. SpO₂ was 92.1%+3.5% in the fenestration children. Spontaneous closure occured in 8.5% of the patients. No severe cyanosis (SpO₂<85%), limb embolism, or stroke. Conclusion Fenestration should not be a routine in children of TCPC. Patients with fenestration or not can obtained satisfactory early clinical efficacy. Atrial septal fenestration should be considered in high-risk children with mPAP higher than 12 mm Hg or serious AVVI and be corrected at the same time. Fenestration contributes to stable circulation after TCPC surgery. It can shorten the duration of pleural effusion.

Citation： LIXia, LIShou-jun, WANGXu, YANJun, YANGJu-xian, ZENGMin, LISheng-li, DUANLei-lei. Early Result of Fenestration on Total Cavopulmonary Connection. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2015, 22(9): 826-830. doi: 10.7507/1007-4848.20150207 Copy

1.	Bridges ND, Lock JE, Castaneda AR. Baffle fenestration with subsequent transcatheter closure. Modification of the Fontan operation for patients at increased risk. Circulation, 1990, 82(5):1681-1689.
2.	Sinha P, Zurakowski D, He D, et al. Intra/extracardiac fenestrated modification leads to lower incidence of arrhythmias after the Fontan operation. J Thorac Cardiovasc Surg, 2013, 145(3):678-682.
3.	Geggel R. Update on the modified Fontan procedure. Curr Opin Cardiol, 1997, 12(1):51-62.
4.	Kopf GS, Kleinman CS, Hijazi ZM, et al. Fenestrated Fontan operation with delayed transcatheter closure of atrial septal defect. J Thorac Cardiovasc Surg, 1992, 103(6):1039-1048.
5.	Harada Y, Uchita S, Sakamoto T, et al. Do we need fenestration when performing two-staged total cavopulmonary connection using an extracardiac conduit? Inter Cardiovasc Thorac Surg, 2009, 9(1):50-55.
6.	Gaynor JW, Bridges ND, Cohen MI, et al. Predictors of outcome after the Fontan operation:is Hypoplastic left heart syndrome still a risk factor? J Thorac Cardiovasc Surg, 2002, 123(2):237-245.
7.	Meyer DB, Zamora G, Wernovsky G, et al. Outcomes of the Fontan procedure using cardiopulmonary bypass with aortic cross-clamping. Ann Thorac Surg, 2006, 82(5):1611-1618.
8.	D'udekem Y, Iyengar AJ, Cochrane AD, et al. The Fontan procedure:contemporary techniques have improved long-term outcomes. Circulation, 2007, 116(11 suppl):1157-1164.
9.	Fiore AC, Tan C, Armbrecht E, et al. Comparison of fenestrated and nonfenestrated patients undergoing extracardiac Fontan. Ann Thorac Surg, 2014, 97(3):924-931.
10.	Anderson R. Pediatric Cardiology. London:Churchill Livingstone, 2009.
11.	Kumar SP, Rubinstein CS, Simsic JM, et al. Lateral tunnel versus extracardiac conduit Fontan procedure:a concurrent comparison. Ann Thorac Surg, 2003, 76(5):1389-1397.
12.	Atz AM, Travison TG, McCrindle BW, et al. Impact of surgical fenestration in a cohort of Fontan patients[abstract]. J Am Coll Cardiol, 2009, 53(suppl A):361A.
13.	Kotani Y, Chetan D, Atlin CR, et al. Longevity and durability of atrioventricular valve repair in single-ventricle patients. Ann Thorac Surg, 2012, 94(6):2061-2069.
14.	Salazar JD, Zarar F, Siddiqui K, et al. Fenestration during Fontan palliation:now the exception instead of the rule. J Thorac Cardiovasc Surg, 2010, 140(1):129-136.
15.	Kotani Y, Chetan D, Saedi A, et al. Persistent fenestration may be a marker for physiologic intolerancd after Fontan completion. J Thorac Cardiovasc Surg, 2014, 148(6):2532-2538.
16.	邹承伟,王安彪. 婴幼儿复杂先天性心脏病的外科治疗. 山东医药, 2004, 44(6):58-60.
17.	Raymond T, Fedderly MD, Beth N, et al. Factors related to pleural effusions after fontan procedure in the era of fenestration. Circulation, 2001, 104(12 suppl 1):1148-1151.
18.	Atz AM, Travison TG, McCrindle BW, et al. Pediatric heart network investigators. late status of fontan patients with persistent surgical fenestration. J Am Coll Cardiol, 2011, 57(24):2437-2443.
19.	王旭, 李守军, 李霞, 等. 全腔静脉肺动脉连接术后ICU延迟恢复患儿风险分层管理. 中国胸心血管外科临床杂志, 2013, 20(3):256-259.
20.	Bradley SM, McCall MM, Sistino JJ, et al. Aorto-pulmonary collateral flow in the Fontan patient:does it matter? Ann Thorac Surg, 2001, 72(2):408-415.
21.	Miyaji K, Nagata N, Miyamoto T, et al. Combined therapy with inhaled nitric oxide and intravenous epoprostenol for critical pulmonary perfusion after the Fontan procedure. J Thorac Cardiovasc Surg, 2003, 125(2):437-439.
22.	Imielski BR, Woods RK, Mussatto, et al. Fontan fenestration closure and event-free survival. J Thorac Cardiovasc Surg, 2013, 145(1):183-187.
23.	Use of a fenestration should be routine during the Fontan procedure:PRO.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu, 2010, 13(1):55-59.

1. Bridges ND, Lock JE, Castaneda AR. Baffle fenestration with subsequent transcatheter closure. Modification of the Fontan operation for patients at increased risk. Circulation, 1990, 82(5):1681-1689.
2. Sinha P, Zurakowski D, He D, et al. Intra/extracardiac fenestrated modification leads to lower incidence of arrhythmias after the Fontan operation. J Thorac Cardiovasc Surg, 2013, 145(3):678-682.
3. Geggel R. Update on the modified Fontan procedure. Curr Opin Cardiol, 1997, 12(1):51-62.
4. Kopf GS, Kleinman CS, Hijazi ZM, et al. Fenestrated Fontan operation with delayed transcatheter closure of atrial septal defect. J Thorac Cardiovasc Surg, 1992, 103(6):1039-1048.
5. Harada Y, Uchita S, Sakamoto T, et al. Do we need fenestration when performing two-staged total cavopulmonary connection using an extracardiac conduit? Inter Cardiovasc Thorac Surg, 2009, 9(1):50-55.
6. Gaynor JW, Bridges ND, Cohen MI, et al. Predictors of outcome after the Fontan operation:is Hypoplastic left heart syndrome still a risk factor? J Thorac Cardiovasc Surg, 2002, 123(2):237-245.
7. Meyer DB, Zamora G, Wernovsky G, et al. Outcomes of the Fontan procedure using cardiopulmonary bypass with aortic cross-clamping. Ann Thorac Surg, 2006, 82(5):1611-1618.
8. D'udekem Y, Iyengar AJ, Cochrane AD, et al. The Fontan procedure:contemporary techniques have improved long-term outcomes. Circulation, 2007, 116(11 suppl):1157-1164.
9. Fiore AC, Tan C, Armbrecht E, et al. Comparison of fenestrated and nonfenestrated patients undergoing extracardiac Fontan. Ann Thorac Surg, 2014, 97(3):924-931.
10. Anderson R. Pediatric Cardiology. London:Churchill Livingstone, 2009.
11. Kumar SP, Rubinstein CS, Simsic JM, et al. Lateral tunnel versus extracardiac conduit Fontan procedure:a concurrent comparison. Ann Thorac Surg, 2003, 76(5):1389-1397.
12. Atz AM, Travison TG, McCrindle BW, et al. Impact of surgical fenestration in a cohort of Fontan patients[abstract]. J Am Coll Cardiol, 2009, 53(suppl A):361A.
13. Kotani Y, Chetan D, Atlin CR, et al. Longevity and durability of atrioventricular valve repair in single-ventricle patients. Ann Thorac Surg, 2012, 94(6):2061-2069.
14. Salazar JD, Zarar F, Siddiqui K, et al. Fenestration during Fontan palliation:now the exception instead of the rule. J Thorac Cardiovasc Surg, 2010, 140(1):129-136.
15. Kotani Y, Chetan D, Saedi A, et al. Persistent fenestration may be a marker for physiologic intolerancd after Fontan completion. J Thorac Cardiovasc Surg, 2014, 148(6):2532-2538.
16. 邹承伟,王安彪. 婴幼儿复杂先天性心脏病的外科治疗. 山东医药, 2004, 44(6):58-60.
17. Raymond T, Fedderly MD, Beth N, et al. Factors related to pleural effusions after fontan procedure in the era of fenestration. Circulation, 2001, 104(12 suppl 1):1148-1151.
18. Atz AM, Travison TG, McCrindle BW, et al. Pediatric heart network investigators. late status of fontan patients with persistent surgical fenestration. J Am Coll Cardiol, 2011, 57(24):2437-2443.
19. 王旭, 李守军, 李霞, 等. 全腔静脉肺动脉连接术后ICU延迟恢复患儿风险分层管理. 中国胸心血管外科临床杂志, 2013, 20(3):256-259.
20. Bradley SM, McCall MM, Sistino JJ, et al. Aorto-pulmonary collateral flow in the Fontan patient:does it matter? Ann Thorac Surg, 2001, 72(2):408-415.
21. Miyaji K, Nagata N, Miyamoto T, et al. Combined therapy with inhaled nitric oxide and intravenous epoprostenol for critical pulmonary perfusion after the Fontan procedure. J Thorac Cardiovasc Surg, 2003, 125(2):437-439.
22. Imielski BR, Woods RK, Mussatto, et al. Fontan fenestration closure and event-free survival. J Thorac Cardiovasc Surg, 2013, 145(1):183-187.
23. Use of a fenestration should be routine during the Fontan procedure:PRO.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu, 2010, 13(1):55-59.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Early Result of Fenestration on Total Cavopulmonary Connection

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