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Ann Thorac Surg 2000;69:1642
© 2000 The Society of Thoracic Surgeons

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Correspondence

Interventional closure of a fenestrated fontan avoids cytokine production

^a Klinik für Pädiatrische Kardiologie, Georg-August-Universität Göttingen, Robert-Koch-Str 40, D-37075 Göttingen, Germany
^b Klinik und Poliklinik für Innere Medizin III, Martin-Luther-Universität Halle, D-06720 Halle, Germany

e-mail: wessel.it{at}t-online.de

To the Editor

The article by Mainwaring and colleagues [1] reports on cytokine generation after modified Fontan procedure. The authors described a significant increase of interleukin-6 (IL-6) levels after cardiopulmonary bypass, whereas tumor necrosis factor- (TNF-) remained almost unaffected. It is of special interest that 11 of the 16 patients had a fenestrated Fontan that had to be closed in the future. Thus, the question raised was whether closure of the fenestration as the final stage of the Fontan procedure would reactivate the production of proinflammatory cytokines.

Therefore, we monitored IL-6, TNF-, and nitric oxide (NO) levels before, as well as 4 and 36 hours after interventional closure of the Fontan fenestration (4 mm: n = 3; 5 mm: n = 1) in 4 children (median age, 4.9 years) by placing an Amplatzer septal occluder (AGA Medical Corp, Golden Valley, MN). As in most of our Fontan patients the cardiac output was significantly decreased and amounted to 2.7 L · min^-1 · m^-2 (calculated by the Fick principle after measuring oxygen consumption). Mean right atrial pressure was elevated to 13.5 mm Hg (median) and the oxygen saturation was 84% (median). After the intervention these variables increased to 15.5 mm Hg and 94.5%, respectively. The median cytokine levels were IL-6: 2 pg/mL before the closure, 4.5 pg/mL at 4 hours, and 0 pg/mL 36 hours thereafter; TNF-: 19, 0, and 0 pg/mL, respectively; and NO: 8, 6.5, and 66.5 mM, respectively. The levels were not significantly changed after the intervention.

In contrast to the activation of the cellular inflammatory cytokine system associated with the first stage of the modified Fontan procedure we show that cytokine elevation was avoided in the final stage if the fenestration was closed by interventional heart catheterization. Thus, we suggest that the negative effects of the systemic inflammatory reaction on the circulation, thyroidal function, and overall morbidity, as outlined by Mainwaring and colleagues [1], can be avoided by the interventional approaches with the Amplatzer septal occluder.

We conclude that, with respect to the modified Fontan procedure, the interventional closure of a fenestration is an ideal completion of the complex surgical approach, avoiding repeated activation of the inflammatory system.

References

1. Mainwaring R.D., Lamberti J.J., Hugli T.E. Complement activation and cytokine generation after modified Fontan procedure. Ann Thorac Surg 1998;65:1715-1720.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Wessel, A. Articles by Loppnow, H. Search for Related Content PubMed Articles by Wessel, A. Articles by Loppnow, H.