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Ann Thorac Surg 1994;57:611-614
© 1994 The Society of Thoracic Surgeons

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Articles

Spontaneous closure of fenestrations in an interatrial Gore-Tex patch: Application to the Fontan procedure

Division of Cardiothoracic Surgery, Department of Surgery, University of California, Los Angeles Medical School, Los Angeles, California USA

Accepted for publication April 26, 1993.

^_* Address reprint requests to Dr Laks, Division of Cardiothoracic Surgery, UCLA Medical Center, CHS 62–181, 10833 LeConte Avenue, Los Angeles, CA 90024.

The concept of the partial Fontan procedure, first described with the adjustable atrial septal defect (ASD) and more recently with the fenestrated technique, has become an accepted approach for the management of highrisk patients undergoing the Fontan procedure. Experience with both techniques has shown that a patent ASD placed in a prosthetic interatrial baffle may close spontaneously over a period of weeks to months. The mechanism and timing of spontaneous closure, as well as the effect of antiplatelet therapy on this process, are poorly understood. To better define this process, the interatrial septum of 15 mongrel dogs was excised and replaced with a fenestrated Gore-Tex (W.L. Gore, Flagstaff, AZ) patch. Postoperative echocardiography confirmed the patency of the ASD and left-to-right shunting. Animals were sacrificed 4 to 6 weeks postoperatively, or sooner if infection or other postoperative complications developed. Eight animals underwent no antiplatelet or anticoagulation therapy postoperatively, and 7 received antiplatelet therapy with aspirin. Patches were removed at the end of the study period and analyzed. By 6 weeks, all 2.7-mm and 4-mm holes had closed spontaneously in all animals that had not received antiptatetet therapy. The earliest closure occurred at 1 week. With antiplatelet therapy, hole closure was found to be delayed but not prevented, and was complete by 6 weeks in all but 1 animal. Histologic examination of the explanted patches revealed that closure was accomplished primarily through the ingrowth of fibrous tissue, accompanied by an inflammatory cell infiltrate. Thrombus formation was uncommon. We conclude that fenestrations placed in a Gore-Tex interatrial patch close spontaneously in a predictable fashion without the risk of thrombus formation. In patients undergoing a Fontan procedure, the presence of a restrictive right-to-left shunt in the early postoperative period has been shown to improve the patient's early postoperative course. Gradual, spontaneous closure of these fenestrations over a period of several weeks would obviate the need for device closure.

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