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Ann Thorac Surg 1989;47:533-538
© 1989 The Society of Thoracic Surgeons

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Articles

When should the hypoplastic right ventricle be used in a fontan operation? An experimental and clinical correlation

Divisions of Cardiovascular-Thoracic Surgery and Cardiology, The Children's Memorial Hospital, and Departments of Surgery and Pediatrics, Northwestern University Medical School, Chicago, Illinois, USA

^_* Address reprint requests to Dr Ilbawi, Division of Cardiovascular-Thoracic Surgery, The Children's Memorial Hospital, 2300 Children's Plaza, Chicago, IL 60614.

Eight anesthetized dogs underwent closure of the tricuspid valve and a Fontan procedure, and the right ventricular cavity was reduced in stepwise fashion. There was an increase in right atrial pressure from 9.3 ± 2.2 to 14.1 ± 2.4 nun Hg (p < 0.001), a decrease in pulmonary artery pulse pressure from 10.8 ± 2.2 to 6.8 ± 2.2 mm Hg (p < 0.01), and a decrease in cardiac index from 2.7 ± 0.3 to 2.2 ± 0.2 L/min/m² (p < 0.001) when the ventricular size was dropped from 50% to 25% of normal. The difference between mean pulmonary artery pressure and mean right atrial pressure, which reflects the positive stroke work index of the ventricle, disappeared once the right ventricular cavity was reduced to 25% of normal (15.0 ± 6.1 versus 14.1 ± 2.4 mm Hg; p = not significant). Experimental results were correlated with postoperative catheterization data from 19 patients with tricuspid atresia who had the Fontan operation. Mean right atrial pressure was 18 ± 4.6 mm Hg and cardiac index was 2.35 ± 0.65 L/ min/m² in patients with a direct atrium-pulmonary artery anastomosis or an atrioventricular anastomosis with a right ventricular cavity less than 39% of normal versus 13 ± 3.2 mm Hg and 3.42 ± 0.46 L/min/m² for those with an atrioventricular connection and a right ventricular cavity greater than 30% of normal (p < 0.05 and p < 0.62, respectively). The right ventricle enlarged from 27% ± 6% of normal preoperativery to 35% ± 10% of normal on follow-up (p < 0.05). Left ventricular ejection fraction was 90% ± 11% of normal in patients with an atriopulmonary anastomosis and 104% ± 16% of normal in those with an atrioventricular connection (p < 0.05). Findings suggest that a right ventricular size that is 30% of normal or less does not contribute to cardiac Output or positive stroke work, whereas a right ventricular size greater than 30% of normal increases stroke volume, decreases systemic venous hypertension, and improves left ventricular function.

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