Skip to main content
SpringerLink
Log in

The role of a staged approach for high-risk Fontan candidates

  • Original Article
  • Published:
The Japanese Journal of Thoracic and Cardiovascular Surgery Aims and scope Submit manuscript

Abstract

The preoperative risk characteristics and surgical outcome were reviewed in 24 patients who underwent a one-stage Fontan procedure (One -stage Group) and in 16 patients who underwent bidirectional cavopulmonary shunt as an interim procedure prior to a subsequent Fontan procedure (Two-stage Group) to clarify the role of the staged approach for high-risk Fontan candidates. There were 2 hospital deaths after the one-stage Fontan, and another 2 after the takedown of the fenestrated Fontan to BCPS in patients considered to be less than ideal candidate because of the presence of 3 or more risk factors. In contrast, among the total of 16 patients in the Two-stage Group who had significantly more risk factors than those in One-stage Group (2.8 ± 1.4, vs 1.1 ± 1.2, p < 0.001), 14 patients survived after bidirectional cavopulmonary shunt, and a subsequent Fontan procedure was accomplished in 12 patients of theses 14, with 2 operative deaths after the takedown to bidirectional cavopulmonary shunt The rate of final Fontan completion in the Two-stage Group (10/16, 62.5%) was considered to be reasonable, considering the fact that this patient group essentially includes non-Fontan candidates. Additionally, in the category of high-risk with 3 or more risk factors, the rate of successful Fontan completion was higher in the Two-stage Group than in the One-stage Group (50% vs 25%). In the survivors of the Two-stage Group, the average number of risk factor decreased from 2.7 ± 1.3 (range 0 to 5) to 1.0 ± 1.0 (range 0 to 4) after bidirectional cavopulmonary shunt with concomitant procedures (ie, extended pulmonary artery reconstruction in 8, and repair of atrioventricular valve regurgitation in 4), predominantly due to improved Fontan candidacy, relating to pulmonary and/or ventricular characteristics, and eliminated anatomical risks. In conclusion, the two-stage approach with bidirectional cavopulmonary shunt accompanied by concomitant repair of associated anomaly may be useful to lower the risk enough to allow subsequent Fontan completion in high-risk patients.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Mayer JE, Helgason H, Jonas RA, Lang P, Vargas FJ, Cook N, Castanada AR. Extending the limits for modified Fontan procedures. J Thorac Cardiovasc Surg 1986; 92: 1021–8.

    PubMed  Google Scholar 

  2. Pridjian AK, Mendelsohn AM, Lupinetti FM, Beekman RH III, Dick M II, Serwer G, et al. Usefulness of the bidirectional Glenn procedure as staged reconstruction for the functional single ventricle. Am J Cardiol 1993; 71: 959–62.

    Article  PubMed  CAS  Google Scholar 

  3. Bridges ND, Jonas RA, Mayer JE, Flanagan MF, Keane JF, Castanada AR. Bidirectional cavopulmonary anastomosis as interim palliation for high-risk Fontan candidates. early results. Circulation 1990; 82 (Suppl IV): IV–170-6.

    Google Scholar 

  4. Hawkins JA, Shaddy RE, Day RW, Sturtevant JE, Orsmond GS, McGough EC. Mid-term results after bidirectional cavopulmonary shunts. Ann Thorac Surg 1993; 56: 833–7.

    Article  PubMed  CAS  Google Scholar 

  5. Mayer JE, Bridges ND, Lock JE, Hanley FL, Jonas RA, Castanada AR. Factors associated with marked reduction in mortality for Fontan operations in patients with single ventricle. J Thorac Cardiovasc Surg 1992; 103: 444–52.

    PubMed  Google Scholar 

  6. Lamberti JJ, Spicer RL, Waldman JD, Grehl TM, Thomson D, George L, et al. The bidirectional cavopulmonary shunt. J Thorac Cardiovasc Surg 1990; 100: 22–30.

    PubMed  CAS  Google Scholar 

  7. Nakata S, Imai Y, Takanashi Y, Kurosawa H, Tezuka K, Nakazawa M, et al. A new method for quantitative standardization of cross-sectional areas of the pulmonary arteries in congenital heart diseases with decreased pulmonary blood flow. J Thorac Cardiovasc Surg 1984; 88: 610–9.

    PubMed  CAS  Google Scholar 

  8. Douville EC, Sade RM, Fyfe DA. Hemi-Fontan operation in surgery for single ventricle: a preliminary report. Ann Thorac Surg 1991; 51: 893–900.

    Article  PubMed  CAS  Google Scholar 

  9. Knott-Craig CJ, Danielson GK, Schaff HV, Puga FJ, Weaver AL, Driscoll DD. The modified Fontan operation: an analysis of risk factors for early postoperative death or takedown in 702 consecutive patients from one institution. J Thorac Cardiovasc Surg 1995; 109: 1237–43.

    Article  PubMed  CAS  Google Scholar 

  10. Driscoll DJ, Offord KP, Feldt RH, Schaff HV, Puga FJ, Danielson GK. Five-to-fifteen year follow-up after Fontan operation. Circulation 1992; 85: 469–96.

    PubMed  CAS  Google Scholar 

  11. Bridges ND, Mayer JE Jr, Lock JE, Jonas RA, Hanley FL, Keane JF, et al. Effect of baffle fenestration on outcome of the modified Fontan operation. Circulation 1992; 86: 1762–9.

    PubMed  CAS  Google Scholar 

  12. Mair DD, Hagler DJ, Puga FJ, Schaff HV, Danielson GK. Fontan operation in 176 patients with tricuspid atresia: results and a proposed new index for patient selection. Circulation 1990; 82 Suppl IV): IV–164-9.

    Google Scholar 

  13. Bridges ND, Farrell PE Jr, Pigott JD III, Norwood WI, Chin AJ. Pulmonary artery index: a nonpredictor of operative survival in patients undergoing modified Fontan repair. Circulation 1989; 80 Suppl I)0 I–216-21.

    Google Scholar 

  14. Masuda M, Kado H, Shiokawa Y, Fukae K, Suzuki M, Murakami E, et al. Clinical results of the staged Fontan procedure in high-risk patients. Ann Thorac Cardiovasc Surg 1998; 65: 1721–25.

    CAS  Google Scholar 

  15. Jonas RA, Bridges ND, Hanley FL, Mayer JE, Castenada AR. Fontan procedure following bidirectional Glenn shunt for high risk patients. J Am Coll Cardiol 1991; 17: 33A.

    Article  Google Scholar 

  16. Mendelsohn AM, Bove EL, Lupinetti FM, Crowley DC, Lloyd TR, Beekman RH III. Central pulmonary artery growth patterns after the bidirectional Glenn procedure. J Thorac Cardiovasc Surg 1994; 107: 1284–90.

    PubMed  CAS  Google Scholar 

  17. Seliem MA, Baffa JM, Vetter JM, Chen SL, Chin AJ, Norwood WI Jr. Changes in right ventricular geometry and heart rate early after hemi-Fontan procedure. Ann Thorac Surg 1993; 55: 1508–12.

    Article  PubMed  CAS  Google Scholar 

  18. Morita K, Ihnken K, Buckberg GD, Sherman MP, Ignarro LJ. Pulmonary vasoconstriction due to impaired nitric oxide production after cardiopulmonary bypass. Ann Thoracic Surg 1996; 61: 1775–80.

    Article  CAS  Google Scholar 

  19. Morita K, Ihnken K, Buckberg GD, Ignarro LJ. Oxidative insults of hyperoxic cardiopulmonary bypass on the infantile heart and lung. Jpn Circulation J 1996; 60: 355–63.

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Cardiovascular Surgery, Jikei University, 3-19-18 Nishishinbashi, Minato-ku, 105-0003, Tokyo, Japan

    Kiyozo Morita, Hiromi Kurosawa, Asatoshi Mizuno, Yoshimasa Sakamoto, Kei Tanaka, Yoshimasa Uno, Noriyasu Kawada, Makoto Hanai & Keiko Sugiyama

Authors
  1. Kiyozo Morita
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Hiromi Kurosawa
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Asatoshi Mizuno
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Yoshimasa Sakamoto
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Kei Tanaka
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Yoshimasa Uno
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Noriyasu Kawada
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Makoto Hanai
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Keiko Sugiyama
    View author publications

    You can also search for this author in PubMed Google Scholar

Additional information

Read at the Fifty-first Annual Meeting of the Japanese Assoication for Thoracic Surgery, Symposium, Tokyo October 2–4, 1998.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Morita, K., Kurosawa, H., Mizuno, A. et al. The role of a staged approach for high-risk Fontan candidates. Jpn J Thorac Caridovasc Surg 47, 478–488 (1999). https://doi.org/10.1007/BF03218047

Download citation

  • Received:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF03218047

Index words

Search

Navigation