Pediatric Cardiology

, Volume 40, Issue 3, pp 468–476 | Cite as

Extubation in the Operating Room After Fontan Procedure: Does It Make a Difference?

  • Sebastian Kintrup
  • Edward Malec
  • Daniela Kiski
  • Christoph Schmidt
  • Andreas Brünen
  • Felix Kleinerüschkamp
  • Hans-Gerd Kehl
  • Katarzyna JanuszewskaEmail author
Original Article


Early extubation appears to have beneficial effects on the Fontan circulation. The goal of this study was to assess the impact of extubation on the operating table in comparison with extubation during the first hours after Fontan operation (FO) on the early postoperative course. Between 2013 and 2016, 114 children with a single ventricle heart malformations (mean age, 3.8 ± 2.3 years) underwent FO: 60 patients were extubated in the operating room (ORE) and 54 in the intensive care unit (ICUE) in the median time of 195 min (range 30–515 min) after procedure. Pre-, peri-, and postoperative records were retrospectively analyzed. The hospital survival rate was 100%. One patient from the ORE group needed an immediate reintubation because of laryngospasm. The ORE group showed lower heart rate (106.5 vs. 120.3 bpm; p < 0.001) and lower central venous pressure (10.4 vs. 11.4 mmHg; p = 0.001) than patients in the ICUE group within the first 24 h after FO, as well as higher systolic blood pressure within 7 h after operation (88.6 ± 2.5 vs. 85.6 ± 2.6 mmHg; p = 0.036). The ORE children manifested significantly less pleural effusions during 48 h after FO (38.0 vs. 49.5 ml/kg; p = 0.004), received less intravenous fluid administration within 24 h after FO (54.1 vs. 73.8 ml/kg; p = 0.019), less inotropic support (9.8 vs. 12.8 h of dopamine; p = 0.033), and less antibiotics (4.7 vs. 5.8 days; p = 0.037). ICUE children manifested metabolic acidosis more frequently than the ORE group 3–4 h after FO (p < 0.05). Immediate extubation after FO in comparison with extubation in the ICU appears to be associated with improved hemodynamics and reduced application of therapeutic interventions in the postoperative course.


Fontan operation Single ventricle Congenital cardiac defects Extubation 



Alanine transaminase


Aspartate transaminase




Balloon angioplasty


Blood gas analysis


Body surface area




Coarctation of the aorta


Cardiopulmonary bypass


Double-inlet left ventricle


Fontan operation


Gamma-glutamyl transferase


Hypoplastic left heart syndrome


Hypoplastic right heart syndrome


Intensive care unit extubation


Inferior vena cava


Low cardiac output syndrome


Left pulmonary artery


Major aortopulmonary collateral artery


Mean pulmonary artery pressure


Operating room extubation




Right pulmonary artery


Right ventricle to pulmonary artery




Single ventricle


Superior vena cava


Single ventricle end diastolic pressure


Transpulmonary pressure gradient


Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

For this type of study formal consent is not required.


  1. 1.
    Barash PG, Lescovich F, Katz JD, Talner NS, Stansel HC (1980) Early extubation following pediatric cardiothoracic operation: a viable alternative. Ann Thorac Surg 29:228–233CrossRefGoogle Scholar
  2. 2.
    Mittnacht AJ, Thanjan M, Srivastava S, Joashi U, Bodian C, Hossain S et al (2008) Extubation in the operating room after congenital heart surgery in children. J Thorac Cardiovasc Surg 136:88–93CrossRefGoogle Scholar
  3. 3.
    Heinle JS, Diaz LK, Fox LS (1997) Early extubation after cardiac operations in neonates and young infants. J Thorac Cardiovasc Surg 114:413–418CrossRefGoogle Scholar
  4. 4.
    DiNardo JA (2011) Con: extubation in the operating room following pediatric cardiac surgery. J Cardiothorac Vasc Anesth 25:877–879CrossRefGoogle Scholar
  5. 5.
    Preisman S, Lembersky H, Yusim Y, Raviv-Zilka L, Perel A, Keidan I et al (2009) A randomized trial of outcomes of anesthetic management directed to very early extubation after cardiac surgery in children. J Cardiothorac Vasc Anesth 23:348–357CrossRefGoogle Scholar
  6. 6.
    Fogel MA, Weinberg PM, Hoydu A, Hubbard A, Rychik J, Jacobs M et al (1997) The nature of flow in the systemic venous pathway measured by magnetic resonance blood tagging in patients having the Fontan operation. J Thorac Cardiovasc Surg 114:1032–1041CrossRefGoogle Scholar
  7. 7.
    Körperich H, Barth P, Gieseke J, Müller K, Burchert W, Esdorn H et al (2015) Impact of respiration on stroke volumes in pediatric controls and in patients after Fontan procedure assessed by MR real-time phase-velocity mapping. Eur Heart J Cardiovasc Imaging 16:198–209CrossRefGoogle Scholar
  8. 8.
    Hsia TY, Khambadkone S, Redington AN, Migliavacca F, Deanfield JE, de Leval MR (2000) Effects of respiration and gravity on infradiaphragmatic venous flow in normal and Fontan patients. Circulation 102:III148–IIII53Google Scholar
  9. 9.
    Cordina RL, O’Meagher S, Karmali A, Rae CL, Liess C, Kemp GJ et al (2013) Resistance training improves cardiac output, exercise capacity and tolerance to positive airway pressure in Fontan physiology. Int J Cardiol 168:780–788CrossRefGoogle Scholar
  10. 10.
    Kawaguchi A, Liu Q, Coquet S, Yasui Y, Cave D (2016) Impact and challenges of a policy change to early track extubation in the operating room for Fontan. Pediatr Cardiol 37:1127–1136CrossRefGoogle Scholar
  11. 11.
    Harris KC, Holowachuk S, Pitfield S, Sanatani S, Froese N, Potts JE et al (2014) Should early extubation be the goal for children after congenital cardiac surgery? J Thorac Cardiovasc Surg 148:2642–2648CrossRefGoogle Scholar
  12. 12.
    Morales DLS, Carberry KE, Heinle JS, McKenzie ED, Fraser CD, Diaz LK (2008) Extubation in the operating room after Fontan’s procedure: effect on practice and outcomes. Ann Thorac Surg 86:576–582CrossRefGoogle Scholar
  13. 13.
    Schuller JL, Sebel PS, Bovill JG, Marcelletti C (1980) Early extubation after Fontan operation. A clinical report. Br J Anaesth 52:999–1004CrossRefGoogle Scholar
  14. 14.
    Redington AN, Penny D, Shinebourne EA (1991) Pulmonary blood flow after total cavopulmonary shunt. Br Heart J 65:213–217CrossRefGoogle Scholar
  15. 15.
    Lomivorotov VV, Efremov SM, Kirov MY, Fominskiy EV, Karaskov AM (2017) Low-cardiac-output syndrome after cardiac surgery. J Cardiothorac Vasc Anesth 31:291–308CrossRefGoogle Scholar
  16. 16.
    Honda T, Itatani K, Takanashi M, Kitagawa A, Ando H, Kimura S et al (2016) Contributions of respiration and heartbeat to the pulmonary blood flow in the Fontan circulation. Ann Thorac Surg 102:1596–1606CrossRefGoogle Scholar
  17. 17.
    Costello JM, Dunbar-Masterson C, Allan CK, Gauvreau K, Newburger JW, McGowan FX Jr et al (2014) Impact of empiric nesiritide or milrinone infusion on early postoperative recovery after Fontan surgery: a randomized, double-blind, placebo-controlled trial. Circ Heart Fail 7:596–604CrossRefGoogle Scholar
  18. 18.
    Gewillig M (2005) The Fontan circulation. Heart 91:839–846CrossRefGoogle Scholar
  19. 19.
    Wernovsky G, Wypij D, Jonas RA, Mayer JE Jr, Hanley FL, Hickey PR et al (1995) Postoperative course and hemodynamic profile after the arterial switch operation in neonates and infants. A comparison of low-flow cardiopulmonary bypass and circulatory arrest. Circulation 92:2226–2235CrossRefGoogle Scholar
  20. 20.
    Lofland GK (2001) The enhancement of hemodynamic performance in Fontan circulation using pain free spontaneous ventilation. Eur J Cardiothorac Surg 20:114–118CrossRefGoogle Scholar
  21. 21.
    Mutsuga M, Quiñonez LG, Mackie AS, Norris CM, Marchak BE, Rutledge JM et al (2012) Fast-track extubation after modified Fontan procedure. J Thorac Cardiovasc Surg 144:547–552CrossRefGoogle Scholar
  22. 22.
    Mascio CE, Wayment M, Colaizy TT, Mahoney LT, Burkhart HM (2009) The modified Fontan procedure and prolonged pleural effusions. Am Surg 75:175–177Google Scholar
  23. 23.
    Yun TJ, Im YM, Jung SH, Jhang WK, Park JJ, Seo DM et al (2009) Pulmonary vascular compliance and pleural effusion duration after the Fontan procedure. Int J Cardiol 133:55–61CrossRefGoogle Scholar
  24. 24.
    Fedderly RT, Whitstone BN, Frisbee SJ, Tweddell JS, Litwin SB (2001) Factors related to pleural effusions after Fontan procedure in the era of fenestration. Circulation 104:I148–I151CrossRefGoogle Scholar
  25. 25.
    Pike NA, Okuhara CA, Toyama J, Gross BP, Wells WJ, Starnes VA (2015) Reduced pleural drainage, length of stay, and readmissions using a modified Fontan management protocol. J Thorac Cardiovasc Surg 150:481–487CrossRefGoogle Scholar
  26. 26.
    Schumacher KR, Stringer KA, Donohue JE, Yu S, Shaver A, Caruthers RL et al (2015) Fontan-associated protein-losing enteropathy and plastic bronchitis. J Pediatr 166:970–977CrossRefGoogle Scholar
  27. 27.
    Fogel MA, Durning S, Wernovsky G, Pollock AN, Gaynor JW, Nicolson S (2004) Brain versus lung: hierarchy of feedback loops in single-ventricle patients with superior cavopulmonary connection. Circulation 110:II147–III52CrossRefGoogle Scholar
  28. 28.
    Mahmoud A-BS, Burhani MS, Hannef AA, Jamjoom AA, Al-Githmi IS, Baslaim GM (2005) Effect of modified ultrafiltration on pulmonary function after cardiopulmonary bypass. Chest 128:3447–3453CrossRefGoogle Scholar
  29. 29.
    McClenahan JB, Young WE, Sykes MK (1965) Respiratory changes after open-heart surgery. Thorax 20:545–554CrossRefGoogle Scholar
  30. 30.
    He S, Chen B, Li W, Yan J, Chen L, Wang X et al (2014) Ventilator-associated pneumonia after cardiac surgery: a meta-analysis and systematic review. J Thorac Cardiovasc Surg 148:3148–3155CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Division of Pediatric Cardiac SurgeryUniversity Hospital MuensterMuensterGermany
  2. 2.Department of Pediatric CardiologyUniversity Hospital MuensterMuensterGermany
  3. 3.Department of AnesthesiologyUniversity Hospital MuensterMuensterGermany

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