Ann Thorac Surg 1996;61:1804
© 1996 The Society of Thoracic Surgeons
Invited Commentary
Invited Commentary
Charles B. Huddleston, MD
Division of Cardiothoracic Surgery, Washington University School of Medicine, 5W 24 Children's Hospital, 1 Children's Place, St. Louis, MO 63110
See also page 1797.
A number of modifications have occurred in the techniques of separating the blue and red blood for patients with single-ventricle physiology since Fontan's original description in 1971. The clinical problems that some of these patients have demonstrated during their long-term follow-up has prompted yet further modifications, the most recent of which are the total cavopulmonary connection and the extracardiac Fontan procedures. The patient with a ``failing Fontan'' presents a significant challenge in terms of medical management, hemodynamic evaluation, and, where appropriate, surgical management. A common reflex response to these patients is transplantation, but even this offers a significant technical challenge due to the number of previous operations, the inherently abnormal iatrogenic systemic venous and pulmonary arterial anomalies, and the congenitally based anatomic abnormalities themselves.
This article by Vitullo and colleagues describes 9 patients with failing Fontan circulations in which the technique of the original Fontan operation consisted of an atriopulmonary connection with or without a conduit, with or without a ``classic'' Glenn shunt-a type of ``old-fashioned'' Fontan, if you will. A careful hemodynamic and angiographic evaluation of these patients was performed looking for a problem in the Fontan circulation, and a surgical solution based on the pathophysiology elucidated was provided. Eight of 9 patients survived, all symptomatically improved, albeit at a relatively short-term follow-up (mean of 20 months). This interesting article serves as a reminder that not all patients presenting with heart failure or other untoward hemodynamic complications of the Fontan procedure require transplantation as the solution. They deserve a very thorough evaluation, based on a high index of suspicion, aimed at detecting problems with the blood flow through the pulmonary vascular bed so that that might be corrected.
Related Article
-
Clinical Improvement After Revision in Fontan Patients
- Dolores A. Vitullo, Serafin Y. DeLeon, Teresa E. Berry, Juan J. Bonilla, Sanjeev V. Chhangani, Frank Cetta, Jose A. Quinones, Timothy J. Bell, and Elizabeth A. Fisher
Ann. Thorac. Surg. 1996 61: 1797-1804.
[Abstract]
[Full Text]
