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Ann Thorac Surg 1993;55:646-651
© 1993 The Society of Thoracic Surgeons

Articles

Pulmonary artery size and clinical outcome after the modified Fontan operation

Christopher J. Knott-Craig, MD*, Paul R. Julsrud, MD, Hartzell V. Schaff, MD, Francisco J. Puga, MD, Gordon K. Danielson, MD

Division of Thoracic and Cardiovascular Surgery and Department of Radiology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA

Accepted for publication June 16, 1992.

* Address reprint requests to Dr Knott-Craig, Division of Thoracic Surgery, University of Oklahoma, Box 26901, Oklahoma City, OK 73190.

The maximum cross-sectional area of the central pulmonary arteries indexed to the body surface area (pulmonary artery index [PAI]) was measured preoperatively from angiograms in 173 patients evaluated for a Fontan-type operation between 1981 and June 1989. Of these, 34 patients underwent another palliative procedure, 8 primarily on the basis of small pulmonary arteries (PAI, 106 to 167 mm2/m2). The mean PAI of this group was significantly smaller than the mean PAI of the remaining 139 patients who underwent a Fontan operation (136 ± 20 versus 310 ± 113 mm2/m2) (p < 0.001). The patients who underwent a Fontan operation were evaluated according to three overlapping end points: (1) hospital death or takedown of repair (12.2%), (2) early failure (cumulative death or takedown of repair within 6 months of operation) (16.5%), and (3) early failure or persistent effusions (33.8%). With regard to these end points, no significant difference in pulmonary artery size could be found between patients having a favorable or unfavorable outcome. However, among a low-risk subset of 30 patients with tricuspid atresia, those with "early failure or persistent effusions" had significantly smaller pulmonary arteries than those with a good outcome (PAI, 185 ±47 versus 276 ± 83 mm2/m2) (p < 0.01). The postoperative transpulmonary gradient of the 8 patients with the smallest pulmonary arteries who underwent a Fontan operation (all PAIs < 170 mm2/m2) was significantly greater than that of the rest of the study group (9.88 ± 2.3 versus 8.13 ± 2.3 mm Hg) (p < 0.04). Small pulmonary arteries, in otherwise good-risk patients, are associated with increased risk of "early failure or persistent effusions" after the Fontan operation. The lowest PAI compatible with success remains unknown. To obtain a more comprehensive assessment of a successful outcome, we suggest that evaluation of patients after a Fontan operation include end points other than hospital death.




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