Ann Thorac Surg 1998;66:933-934
© 1998 The Society of Thoracic Surgeons
Case Reports
Extracardiac fontan operation with tube fenestration allowing transcatheter coil occlusion
Shubhayan Sanatani, MDa,
Suvro S. Sett, MDa,
Derek G. Human, BM, BCha,
J.A. Gordon Culham, MDb,
Jacques G. LeBlanc, MDa
a Cardiac Sciences, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
b Department of Radiology, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
Accepted for publication March 19, 1998.
Please address reprint requests to Dr Sett, Cardiac Sciences, British Columbia Children’s Hospital, 4480 Oak St, Vancouver, BC V6H 3V4, Canada
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Abstract
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A fenestration may improve the immediate postoperative course after a Fontan procedure by preserving the cardiac output. We describe a simple and safe technique of fenestration amenable to coil occlusion, which can be carried out in most cardiac catheterization laboratories.
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Introduction
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The fenestrated Fontan operation has been shown to improve operative survival and shorten the duration of hospital stay and pleural effusions [1–3]. Postoperatively, the fenestration may close spontaneously, may be closed with a snare, or may be occluded by catheter intervention [1–3]. Catheter-directed closure has been described with use of an umbrella device, which is not available in most centers and does not have Food and Drug Administration approval [4–6]. Meanwhile, many centers are reporting successful experience with coil occlusion of patent ductus arteriosus [7]. We report a technique of fenestration for the extracardiac Fontan operation that facilitates postoperative coil occlusion of the fenestration.
At the age of 4 weeks an infant with an unbalanced atrioventricular septal defect, hypoplastic left ventricle, double-outlet right ventricle, and anterior and rightward aorta underwent pulmonary artery banding at another institution. When the patient was 2 years of age, a cavopulmonary shunt was performed without removal of the pulmonary artery band. When seen at our center at the age of 6 years, he was relatively well with saturations of 85% and a hemoglobin level of 160 g/L, but he had a limited exercise tolerance because of increased cyanosis. At cardiac catheterization, mean pulmonary artery pressures were 12 mm Hg; ventricular function was normal as assessed by the low end-diastolic pressure and qualitatively normal wall motion. There was mild atrioventricular valve regurgitation and distortion at the bifurcation of his pulmonary arteries secondary to the pulmonary artery band. Although systolic narrowing was present in the subaortic area, there was no evidence of subaortic obstruction on isoproterenol challenge. The patient underwent a Damus-Kaye-Stansel anastomosis, right pulmonary arterioplasty, and a 20-mm stretch Gore-Tex graft (W.L. Gore and Associates, Flagstaff, AZ) was anastomosed end-to-end from the divided inferior vena cava to the inferior aspect of the right pulmonary artery. An 8-mm Gore-Tex graft was anastomosed end-to-side from the extracardiac conduit to the right atrium to create a fenestration. The graft was then clipped in its central portion with two large Weck clips (Ethicon, Johnson and Johnson, Arlington, TX) to decrease the circumference by one half, approximating a 4-mm fenestration and making the location of the fenestration easily identifiable on fluoroscopy.
The patient’s postoperative course was complicated by junctional ectopic tachycardia and staphylococcal bacteremia. Chest tubes were removed by day 14. After a prolonged course of intravenous antibiotics, he was discharged 5 weeks postoperatively receiving warfarin, captopril, digoxin, and furosemide.
At follow-up, despite an improvement in his overall energy level, he continued to be desaturated, with saturations of 80% in room air. A perfusion scan 3 months after his modified Fontan operation showed preferential flow to the right lung and cardiac catheterization revealed a stenosis of the left pulmonary artery. A 14-mm Schneider Wallstent (Pfizer Schneider (Canada), Toronto, Canada) was placed with resultant improved flow to the left lung. The fenestration was test occluded at this catheterization with a resultant 2 mm Hg increase in his right atrial pressures and an improvement in his saturations.
Six months later a repeat catheterization was performed with the intention of occluding the fenestration. The fenestration was easily located with the Weck clips (Fig 1) and entered with a 6F angiography balloon catheter (Arrow Medical, Mississauga, Ontario, Canada), and a test occlusion was performed with hemodynamic monitoring. Oxygen saturations improved from 83% to 98%, and pressures in the Fontan circulation increased from 10 mm Hg to 12 mm Hg. With the use of a 5F nontapered end-hole catheter (Cook [Canada], Toronto, Canada), a Jackson detachable 5 by 5-mm loop coil (Cook [Canada]) was placed astride the Weck clips with good stability, but a hand injection demonstrated a residual shunt. A second 5-mm coil was placed in the graft, resting on the first, which resulted in total occlusion of the fenestration (Fig 2). The oxygen saturations increased to 99% and the pressure in the Fontan circulation remained 12 mm Hg. The patient was discharged home the following day, with no complications. When last seen, he was fully saturated on room air and in New York Heart Association class I.
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Fig 1. Frontal projection shows the end-hole catheter engaged in the systemic venous side of the fenestration. Contrast can be seen entering the pulmonary venous atrium. The curved arrow marks the Weck clips. The previously placed Wallstent can be seen in the pulmonary artery.
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Fig 2. Lateral projection showing the first coil astride the narrowing demarcated by Weck clips (curved arrow). A second coil (straight arrow) is being placed on the systemic venous side of the graft fenestration. Note the residual external pacemaker wires from previous operations.
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Comment
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A fenestration may improve the operative mortality and shorten the duration of chest tube drainage in patients undergoing the Fontan procedure for palliation of complex congenital heart disease [1–3]. An extracardiac connection between the transected inferior vena cava and the pulmonary arteries with a snare-controlled Gore-Tex tube has been described by Black and associates [8]. In that report, the snare was used to control the size of the fenestration, allowing for closure in the late postoperative period. The occlusion of uncontrolled fenestrations has been approached in a variety of ways, primarily using umbrella devices [1–4].
Recently, coil occlusion has become a recognized treatment modality for patent ductus arteriosus [7]. With the Gore-Tex tube, the fenestration behaves somewhat like a patent ductus arteriosus. The 8-mm tube allows construction of large, patent anastomoses. Placement of the Weck clips narrows the Gore-Tex tube to provide an acceptable size of fenestration in the immediate postoperative period (personal communication; Dr F. Hanley). The large clips used also facilitated coil embolization in several ways: by providing a landmark easily identified under fluoroscopy, providing stability for the coils, and reducing the risk of dislodgment of the coil. The use of the Jackson detachable coil reduces the risk of systemic coil embolization.
The spontaneous closure of fenestrations is well recognized. However, in situations with good Fontan hemodynamics and failure of closure, we have provided a technique of fenestration that allows simple and safe closure available in most interventional cardiac catheterization laboratory settings.
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References
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- Laks H., Pearl J.M., Haas G.S., et al. Partial Fontan: advantages of an adjustable interatrial communication. Ann Thorac Surg 1991;52:1084-1095.[Abstract]
- Bridges N.D., Castañeda A.R. The fenestrated Fontan procedure. Herz 1992;17:242-245.[Medline]
- Kopf G.S., Kleinman C.S., Hijazi Z.M., Fahey J.T., Dewar M.L., Hellenbrand W.E. Fenestrated Fontan operation with delayed transcatheter closure of atrial septal defect. J Thorac Cardiovasc Surg 1992;103:1039-1048.[Abstract]
- Sommer R.J., Recto M., Golinko R.J., Griepp R.B. Transcatheter coil occlusion of surgical fenestration after Fontan operation. Circulation 1996;94:249-252.[Abstract/Free Full Text]
- Rome J.J., Keane J.F., Perry S.B., Spevak P.J., Lock J.E. Double-umbrella closure of atrial defects. Circulation 1990;82:751-758.[Abstract/Free Full Text]
- Rocchini A.P. Transcatheter closure of atrial septal defects. Circulation 1990;82:1044-1045.[Free Full Text]
- Rothman A., Lucas V.W., Sklansky M.S., Cocalis M.W., Kashani I.A. Percutaneous coil occlusion of patent ductus arteriosus. J Pediatr 1997;130:447-454.[Medline]
- Black M.D., van Son J.A.M., Haas G.S. Extracardiac Fontan operation with adjustable communication. Ann Thorac Surg 1995;60:716-718.[Abstract/Free Full Text]
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T. J. Bradley, D. G. Human, J.A. G. Culham, W. J. Duncan, M. W. H. Patterson, J. G. LeBlanc, and S. S. Sett
Clipped tube fenestration after extracardiac Fontan allows for simple transcatheter coil occlusion
Ann. Thorac. Surg.,
December 1, 2003;
76(6):
1923 - 1928.
[Abstract]
[Full Text]
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Abstract
Introduction
