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“A new surgical procedure has been used which transmits the whole vena caval blood to the lungs, while only oxygenated blood returns to the left heart. The right atrium is, in this way, ‘ventriclized’, to direct the inferior vena caval blood to the left lung, the right pulmonary artery receiving the superior vena caval blood through a cava-pulmonary anastomosis”. By this statement, Fontan and Baudet started their article detailing the first Fontan procedure in 1971 [6].
Since 1971, the Fontan procedure has been applied for palliation of single-ventricle physiology patients. Multiple modifications of the original procedure were applied to improve morbidities and mortalities. Numerous investigators studied the short- and long-term outcomes of the procedure [5, 7]. The 32nd Bethesda conference in 2001 discussed the issue of caring of these patients going into adolescent and adulthood [1]. It is around the same time when The British Cardiac Society released its report detailing plans for care of the grown-up with congenital heart disease [12]. The rise of the new adult congenital heart disease specialty was dictated by the need for appropriate care given to the growing number of patients that currently exceeded the number of children with congenital heart disease, thanks to advances in medicine and surgery.
One of the risk factors of failing Fontan, also a result of Fontan, is the presence of aorto-pulmonary collateral arteries (APCs). APCs are present in up to 80 % of single-ventricle patients undergoing pre-Fontan catheterization. Pre-Fontan coil occlusion of these vessels decreases single-ventricle volume load and improves outcome after Fontan procedure [8, 9, 14, 16]. These collateral vessels are usually branches of the right and left subclavian arteries including the left internal mammary artery (LIMA) and the right internal mammary artery (RIMA). Branches of subclavian arteries and intercostal arteries normally have extensive anastomotic connections with LIMA and RIMA. Successful occlusion of the APCs requires obliteration of the whole length of the vessel to prevent revascularization by distal feeder tributaries. In adults with coronary artery disease not amenable to percutaneous stenting, coronary artery bypass grafting (CABG) is the standard of care. LIMA is used in almost every patient and is the cardiac surgeon’s blood vessel of choice for CABG due to its superior long-term patency compared to other vessels [2, 10]. RIMA is used in less number of CABG cases due to the lack of anatomical proximity to the target coronary vessels. It is usually used in grafting the right coronary artery when feasible with patency equivalent to LIMA. Other arterial and venous grafts options are less frequently used with variable patency. The internal mammary arteries are strikingly resistant to the development of atherosclerosis secondary, at least in part, to its superior endothelial function with fewer fenestrations, lower intercellular junction permeability, greater anti-thrombotic molecules such as heparin sulfate and tissue plasminogen activator, higher endothelial nitric oxide (NO) production and its impermeability to the transfer of atherosclerosis producing lipoproteins [17].
Early cases of single-ventricle physiology palliated with Fontan procedure are in their 30 and 40s. This group of patients is approaching the common age of coronary artery disease. In the next 10–20 years, increasing number of these patients will require management of their coronary artery disease either via percutaneous route or CABG if not candidate for percutaneous modalities.
The increased incidence of coiling of APCs in single-ventricle physiology patients, particularly LIMA and RIMA, will carry a future challenge to surgical teams caring for these patients. The incidence of LIMA versus RIMA coiling is poorly described in the literature. A Pubmed search revealed many articles investigating pre-Fontan coiling of APCs without clear specification of the vessel(s) being coiled [3, 4, 15]. A study designed to evaluate this incidence would be a great start. Although coiled LIMA and RIMA leading to lack of adequate graft vessels with high-quality patency appear to be the most stressing future concern in Fontan patients, it is not the only surgical issue in such circumstances. Re-do sternotomy and minimal experience of adult cardiothoracic surgery teams in performing CABG in single-ventricle patients previously palliated by Fontan procedure are two other examples. These issues and others were addressed to some extent in the literature, and their solutions have been proposed and implemented [11, 13]. Hybrid teams consisting of adult and congenital cardiologists and cardiothoracic surgeons may be the ideal team to manage these patients in the operating room and the immediate post-operative period. A surgical specialty equivalent to adult congenital heart disease may be another way to address this matter. Prospective studies evaluating the incidence of each coiled APC keeping in mind the future CABG for these patients may be warranted. Such a study would shed some light on the subject and thus would allow for further prospective studies.
References
32nd Bethesda Conference report (2001) Care of the adult with congenital heart disease. J Am Coll Cardiol 37(5)
Arima M, Kanoh T, Suzuki T et al (2005) Serial angiographic follow-up beyond 10 years after coronary artery bypass grafting. Circ J 69(8):896–902
Banka P, Sleeper LA, Atz AM et al (2011) Practice variability and outcomes of coil embolization of aortopulmonary collaterals before Fontan completion: a report from the Pediatric Heart Network Fontan Cross-Sectional Study. Am Heart J 162(1):125–130
Dori Y, Glatz AC, Hanna BD et al (2013) Acute effects of embolizing systemic-to-pulmonary arterial collaterals on blood flow in patients with superior cavopulmonary connections: a pilot study. Circ Cardiovasc Interv 6(1):101–106
Driscoll DJ, Offord KP, Feldt RH et al (1992) Five- to fifteen-year follow-up after Fontan operation. Circulation 85(2):469–496
Fontan F, Baudet E (1971) Surgical repair of tricuspid atresia. Thorax 26(3):240–248
Gewillig M (2005) The Fontan circulation. Heart 91(6):839–846
Ichikawa H, Yagihara T, Kishimoto H et al (1995) Extent of aortopulmonary collateral blood flow as a risk factor for Fontan operations. Ann Thorac Surg 59:433–437
Kanter KR, Vincent RN, Raviele AA (1999) Importance of acquired systemic-to-pulmonary collaterals in the Fontan operation. Ann Thorac Surg 68:969–975
Kitamura S, Kawachi K, Kawata T et al (1996) Ten-year survival and cardiac event-free rates in Japanese patients with the left anterior descending artery revascularized with internal thoracic artery or saphenous vein graft: a comparative study. Nippon Geka Gakkai zasshi 97(3):202–9
Moodie D (2011) Adult congenital heart disease: past, present, and future. Tex Heart Inst J 38(6):705–706
Report of the British Cardiac Society Working Party (2002) Grown-up congenital heart (GUCH) disease: current needs and provision of service for adolescents and adults with congenital heart disease in the UK. Heart 88(Suppl 1):i1–i14
Sable C, Foster E, Uzark K et al (2011) Best practices in managing transition to adulthood for adolescents with congenital heart disease: the transition process and medical and psychosocial issues: a scientific statement from the American Heart Association. Circulation 123(13):1454–1485
Spicer RL, Vzark KC, Moore JW et al (1996) Aortopulmonary collateral vessels and prolonged pleural effusions after modified Fontan procedures. Am Heart J 131:1164–1168
Stern HJ (2010) Aggressive coiling of aortopulmonary collaterals in single-ventricle patients is warranted. Pediatr Cardiol 31(4):449–453
Triedman JK, Bridges ND, Mayer JE et al (1993) Prevalence and risk factors for aortopulmonary collateral vessels after Fontan and bidirectional Glenn procedures. J Am Coll Cardiol 22:207–215
Zulli A, Hare DL, Horrigan M et al (2003) The resistance of the IMA to atherosclerosis might be associated with its higher eNOS, ACE and ET-A receptor immunoreactivity. Arterioscler Thromb Vasc Biol 23(7):1308
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Awad, S., Abdelhady, K. Coronary Artery Bypass Grafting in Single-Ventricle Patients Palliated with Fontan Procedure: Future Consideration. Pediatr Cardiol 36, 251–252 (2015). https://doi.org/10.1007/s00246-014-1072-6
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DOI: https://doi.org/10.1007/s00246-014-1072-6