Ann Thorac Surg 1998;66:1826-1828
© 1998 The Society of Thoracic Surgeons
How To Do It
Extracardiac conduit fontan procedure without cardiopulmonary bypass
Doff B. McElhinney, MDa,
Edwin Petrossian, MDa,
V. Mohan Reddy, MDa,
Frank L. Hanley, MDa
a Division of Cardiothoracic Surgery, University of California, San Francisco, San Francisco, California, USA
Accepted for publication June 9, 1998.
Address reprint requests to Dr Hanley, UCSF Medical Center, 505 Parnassus Ave, M593 San Francisco, CA 94143-0118
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Abstract
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There are a number of potential advantages of extracardiac conduit cavopulmonary anastomosis for palliation of functional single ventricle heart disease, including the ability to perform the operation with no aortic cross-clamping and with minimal duration of extracorporeal circulation. In many patients, it may be possible to perform the procedure without cardiopulmonary bypass altogether. In this report, we present our technique for performing the extracardiac conduit Fontan operation without cardiopulmonary bypass.
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Introduction
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Total cavopulmonary anastomosis using an extracardiac conduit has gained increasing acceptance in the surgical repertoire for palliation of functional univentricular heart disease [1, 2]. There are a number of potential advantages of the extracardiac conduit approach over other modifications of the Fontan procedure, including superior preservation of ventricular and pulmonary vascular function in the early postoperative period, a reduced likelihood of supraventricular arrhythmias or sinus node dysfunction, and improved hydrodynamics in the cavopulmonary connection [3]. In our experience, one of the most important technical benefits of the extracardiac conduit approach has been the ability to complete the Fontan circulation without cardioplegic arrest of the heart and with minimal duration of cardiopulmonary bypass. As we have refined our technique for performing the extracardiac Fontan procedure, we have gradually reduced our bypass time and adopted a strategy of partial bypass with continued perfusion of the lungs through the previously performed bidirectional superior cavopulmonary anastomosis. Recently, we have pushed this strategy further, performing the entire operation without cardiopulmonary bypass in some cases. In this report, we present our technique for this procedure.
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Technique
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Through a standard median sternotomy, the ascending aorta, pulmonary arteries, and superior (SVC) and inferior venae cavae (IVC) are dissected free using electrocautery to minimize bleeding. The diameter of the IVC is inspected and a polytetrafluoroethylene tube or aortic allograft conduit of appropriate size is selected. The craniad end of the conduit is cut with a bevel in order to increase the cross-sectional area of the anastomosis and to optimize hydrodynamic efficiency of the cavopulmonary connection [3]. Purse-string sutures are placed in the aorta, IVC, and SVC, and right atrium (Fig 1). To improve exposure, the purse-string suture in the IVC is positioned as low as possible, with additional length gained on the infradiaphragmatic cava by taking down the pericardial reflection on the IVC and mobilizing the vessel to the level of the hepatic veins. Heparin is administered intravenously, using half of the standard dose (150 U/kg). A side-biting vascular clamp is applied to the undersurface of the central right pulmonary artery in such a fashion that flow from the bidirectional cavopulmonary anastomosis continues to perfuse both lungs (Fig 1). The clamp is placed to the left of the bidirectional cavopulmonary anastomosis, and should include the main pulmonary artery if one is present and patent. In patients with a main pulmonary artery, this is clamped and divided, and the cardiac end is oversewn. An arteriotomy is performed on the anteroinferior aspect of the central right pulmonary artery (the portion isolated by the side-biting clamp), and the craniad end of the graft is sewn to the incision with a continuous polypropylene suture (Fig 2). After completion of the anastomosis, the graft is clamped at its midportion and the side-biting clamp is removed from the pulmonary artery. The position of the anastomosis can be modified as necessary. Anastomotic leaks are repaired with polypropylene sutures.
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Fig 1. Purse-string sutures are placed in the right atrial appendage and low in the inferior vena cava for cavoatrial bypass during the inferior vena cava to conduit anastomosis. In case bypass is required, pursestring sutures are also placed in the ascending aorta and high in the superior vena cava. A side-biting clamp is placed along the underside of the pulmonary artery and and an anteroinferior pulmonary arteriotomy is performed.
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Fig 2. Using continuous polypropylene suture, the beveled superior end of the conduit is anastomosed to the arteriotomy in the segment of pulmonary artery isolated by the side-biting clamp.
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An IVC to right atrium shunt is then created in preparation for the IVC conduit anastomosis. Venous cannulas are placed in the right atrium and IVC through previously placed purse-string sutures, then connected to one another with a segment of tubing. Two straight vascular clamps are placed across the IVC: one at the cavoatrial junction, taking care to avoid injury to the coronary sinus and the right coronary artery, and the other just above the cannula (Fig 3). The IVC is divided between the two clamps with a moderate bevel to allow for a nonstenotic anastomotic lumen, leaving sufficient length on the caudad segment to facilitate the subsequent anastomosis. The cardiac stump of the IVC is doubly oversewn with running polypropylene suture and the upper clamp is removed. The caudad end of the graft is cut with a similar bevel and anastomosed to the IVC with a running polypropylene suture (Fig 4). The graft is also tailored to provide a mild anterior and lateral curvature in order to avoid compression of the pulmonary veins. The graft is deaired by removing the inferior caval clamp before tightening the proximal anastomosis, and the IVC-right atrium bypass cannulas are removed. The position of the graft is inspected with special attention to possible pulmonary artery distortion or pulmonary vein compression.
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Fig 3. After completion of the conduit to pulmonary artery anastomosis, the side-biting clamp is removed from the pulmonary artery and the conduit is deaired and cross-clamped. Inferior vena cava to right atrium bypass is established with two venous cannulas connected together. Two straight vascular clamps are placed across the inferior vena cava above the cannula, and the inferior vena cava is divided between them (dashed line).
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Fig 4. The cardiac end of the divided inferior vena cava has been oversewn, and the inferior vena cava to conduit anastomosis is being performed with continuous polypropylene suture.
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Pressure monitoring catheters are placed in the conduit via the IVC and in the common atrium via the right atrial appendage. A fenestration is not routinely placed, but if the Fontan pressure is >18 mm Hg with a transpulmonary gradient >10 mm Hg, consideration is given to placing a fenestration between the conduit and the right atrial free wall either by side-to-side anastomosis or with a 4 to 8 mm vascular graft. Either technique can be performed without cardiopulmonary bypass with the aid of partial occlusion vascular clamps.
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Comment
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Among patients undergoing the Fontan operation, the instantaneous hazard for death or Fontan failure is highest in the early postoperative period [4]. In order to optimize early postoperative outcome, it is essential to maintain a stable and favorable hemodynamic state. Three critical components of ensuring such a result are preservation of ventricular and pulmonary vascular function and avoidance of arrhythmias. Cardiopulmonary bypass, cardioplegic arrest, and intracardiac procedures can be major contributing factors to impaired systolic and diastolic ventricular function, pulmonary vascular dysfunction, and rhythm abnormalities. Therefore, if the Fontan procedure can be performed safely and effectively without cardiopulmonary bypass, substantial improvements in early postoperative outcome can likely be achieved.
The ability to perform the extracardiac conduit Fontan procedure without cardiopulmonary bypass depends on a number of variables. Obviously, bypass will be required if intracardiac procedures are necessary. Therefore, any such procedures must be performed before Fontan completion, preferably at the time of bidirectional cavopulmonary anastomosis. Stenoses of the pulmonary arteries can be relieved using side-biting clamps during the Fontan operation, although more extensive pulmonary arterioplasty procedures may necessitate bypass. A second requirement for performing the Fontan procedure without bypass is sufficiently large pulmonary arteries that the side-biting clamp can be placed without occluding superior caval flow to the lungs. Because we generally wait until the patient has reached a weight of 
15 kg to complete the Fontan circulation, in order to ensure that an adult-sized conduit (20 to 22 mm) can be used, the pulmonary arteries are typically of adequate caliber that pulmonary perfusion is not compromised by using the side-biting clamp. If a side-biting clamp cannot be applied without occluding flow, it may be possible in some cases to cross-clamp the pulmonary artery and perform the inferior cavopulmonary anastomosis off bypass with the superior cavopulmonary connection perfusing only one lung.
Indications for performing the extracardiac conduit Fontan procedure without cardiopulmonary bypass are not well established. Others have employed this approach in patients at particular risk for cardiopulmonary bypass [5]. However, bypass may have some degree of detrimental effect on all patients receiving a Fontan circulation, and this approach may thus be indicated on a wider basis. It is important to be prepared and willing to initiate bypass if there is any question about the safety of the no-bypass approach. Therefore, hemodynamics and oxygen saturation must be monitored closely, and purse-string sutures are placed in the SVC and aorta, with the bypass pump primed and on standby. With additional experience, it may be possible to predict better which patients will be best served by this strategy.
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References
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- Nawa S., Teramoto S. New extension of the Fontan principle: inferior vena cava-pulmonary artery bridge operation. Thorax 1988;43:1022-1023.[Abstract/Free Full Text]
- Amodeo A., Galletti L., Marianeschi S., et al. Extracardiac Fontan for complex cardiac anomalies: seven years’ experience. J Thorac Cardiovasc Surg 1997;114:1020-1031.[Abstract/Free Full Text]
- De Leval M.R., Dubini G., Migliavacca F., et al. Use of computational fluid dynamics in the design of surgical procedures: application to the study of competitive flows in cavopulmonary connections. J Thorac Cardiovasc Surg 1996;111:502-513.[Abstract/Free Full Text]
- Fontan F., Kirklin J.W., Fernandez G., et al. Outcome after a "perfect" Fontan operation. Circulation 1990;81:1520-1536.[Abstract/Free Full Text]
- Burke R.P., Jacobs J.P., Ashraf M.H., Aldousany A., Chang A.C. Extracardiac Fontan operation without cardiopulmonary bypass. Ann Thorac Surg 1997;63:1175-1177.[Abstract/Free Full Text]
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Abstract
Introduction
