Improvement of Fontan Circulatory Failure after Conversion to Total Cavopulmonary Connection

Park, Han Ki; Yi, Gijong; Song, Suk Won; Lee, Sak; Park, Young Hwan; Cho, Bum Koo

Abstract

BACKGROUND: By improving the flow pattern in Fontan circuit, total cavopulmonary connection (TCPC) could result in a better outcome than atriopulmonary connection Fontan operation. For the patients with impaired hemodynamics after atriopulmonary Fontan connection, conversion to TCPC can be expected to bring hemodynamic and functional improvement. We studied the results of the revision of the previous Fontan connection to TCPC in patients with failed Fontan circulation. MATERIAL AND METHOD: From October 1979 to June 2002, eight patients who had failed Fontan circulation, underwent revision of previous Fontan operation to TCPC at Yonsei University Hospital. Intracardiac anomalies of the patients were tricuspid atresia (n=4) and other functional single ventricles (n=4). Mean age at TCPC conversion was 14.0+/-7.0 years (range, 4.6~26.2 years) and median interval between initial Fontan operation and TCPC was 7.5 years (range, 2.4~14.3 years). All patients had various degree of symptoms and signs of right heart failure. NYHA functional class was III or IV in six patients. Paroxysmal atrial fibrillation (n=1), cyanosis (n=2), intraatrial thrombi (n=2), and protein losing enteropathy (PLE) (n=3) were also combined. The previous Fontan operation was revised to extracardiac conduit placement (n=7) and intraatrial lateral tunnel (n=1). RESULT: There was no operative death. Major morbidities included deep sternal infection (n=1), prolonged pleural effusion over two weeks (n=1), and temporary junctional tachyarrhythmia (n=1). Postoperative central venous pressure was lower than the preoperative value (17.9+/-3.5 vs. 14.9+/-1.0, p=0.049). Follow-up was complete in all patients and extended to 50.1 months (mean, 30.3+/-12.8 months). There was no late death. All patients were in NYHA class I or II. Paroxysmal supraventricular tachycardia developed in a patient who underwent conversion to intraatrial lateral tunnel procedure. PLE was recurred in two patients among three patients who had had PLE before the convertsion. There was no newly developed PLE.
CONCLUSION
Hemodynamic and functional improvement could be expected for the patients with Fontan circulatory failure after atriopulmonary connection by revision of their previous circulation to TCPC. The conversion could be performed with low risk of morbidity and mortality.