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Ann Thorac Surg 2002;74:931-932
© 2002 The Society of Thoracic Surgeons

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Case report

Diaphragmatic fenestration for resistant pleural effusions after univentricular repair

^a Cardiothoracic Center, All India Institute of Medical Sciences, New Delhi, India

Accepted for publication April 1, 2002.

* Address reprint requests to Dr Sharma, Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar 110029, New Delhi 110029, India
e-mail: rsharmacvs{at}hotmail.com

	Abstract

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A 12-year-old child with chronic pleural effusions for a month and a half after a fenestrated Fontan operation underwent bilateral diaphragmatic fenestrations with complete relief. We suggest this approach as an alternative treatment for chronic pleural effusions that may ensue after total cavopulmonary connection.

	Introduction

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Pleural effusion after Fontan procedures is a common and debilitating complication [1, 2]. The incidence of significant pleural effusions in our experience is about 15% [3]. The causes of these effusions include elevated right atrial pressure (RAP), infection, hypoproteinemia, renal dysfunction, and postpericardiotomy syndrome. On most occasions a cause other than elevated RAP cannot be identified and the treatment generally has consisted of repeated thoracenteses, diuretics, fluid restriction, pleurodesis, and pleuroperitoneal shunt [1–6]. We describe a novel solution to this problem.

A 12-year-old boy weighing 30 kg presented with cyanosis. Echocardiographic evaluation showed situs inversus, atrioventricular discordance, ventriculoarterial discordance, subpulmonic ventricular septal defect, pulmonary stenosis (gradient of 65 mm Hg), and hypoplasia of the systemic right ventricle. Cardiac catheterization of the patient revealed pulmonary artery mean pressure was 16 mm Hg with ventricular pressure of 120 to 130/16 mm Hg. Systemic oxygen saturation was 55%. Pulmonary arteries were confluent and good sized. A fenestrated (4 mm) total cavopulmonary connection was performed. A 0.6 mm thick polytetrafluoroethylene patch (Gore-Tex; W. L. Gore, Flagstaff, AZ) was used to create an intraatrial tunnel and fenestration was performed with a 4-mm aortic punch (Scanlan, St Paul, MN). The child withstood the surgery well and the postoperative course in the intensive care unit was uneventful in terms of extubation (12 hours postoperatively) and weaning off inotropic agents. The superior vena caval pressure ranged from 8 to 12 mm Hg, and the atrial tunnel pressure ranged from 7 to 14 mm Hg. However, there was persistent drainage from both the left-side and the right-side chest tubes (placed electively intraoperatively). The average drainage from both the tubes was 400 to 500 mL per day. This drainage continued for more than 6 weeks postoperatively and was managed conservatively by a high-protein diet and replacing the chest tube losses with fresh frozen plasma and 10% human albumin. Echocardiography showed a good nonobstructed Fontan circuit with patent fenestration. As ascites was not present it was decided the patient should undergo bilateral diaphragmatic fenestration. Informed consent was taken and the novelty of the procedure and the possibility of its failure was explained. Antibiotic prophylaxis with cefotaxime and amikacin was initiated.

The patient was intubated with a double-lumen endotracheal tube under general anesthesia. He was placed in a left lateral position and the approach was through a right posterolateral thoracotomy incision. The seventh intercostal space was entered. All loculations and adhesions were released. A thorough toilette of the pleural cavity was done using warm saline wash admixed with gentamicin. A circular incision with a diameter of about 3 cm was made with electrocautery on the diaphragm in the region of central tendon over the bare area of the liver. This portion of the diaphragm was then excised using electrocautery. Hemostasis was achieved. A commercially available polypropylene mesh (Prolene mesh; Johnson and Johnson, Somerville, NJ) was sized to fit the diaphragmatic opening and was then sutured to the orifice using continuous 3-0 polypropylene suture. A 28F chest tube was inserted for drainage. After achieving hemostasis the thoracotomy wound was closed in layers. A sterile dressing was applied and the drapes were removed. The patient was turned and placed in the right lateral position. Cleaning and draping was performed again. A left posterolateral thoracotomy was performed. A similar procedure was performed on the left side. The chest tube drainage on the first postoperative day was 230 mL (both tubes) and subsequently decreased to 170 mL, 130 mL, 60 mL, and 20 mL, respectively, on postoperative days 2, 3, 4, and 5. Chest tubes were removed on day 7 and the patient was discharged after 2 days. Six months postoperatively he continues to be in functional class 1 with no further effusions.

	Comment

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Significant pleural effusions complicate about 15% of the fenestrated Fontan procedures in our center [3]. Our patient was in sinus rhythm and had no evidence of elevated right atrial pressure, postpericardiotomy syndrome, infection, hypoproteinemia, or renal dysfunction. After treating our patient along the conventional lines we decided to perform the diaphragmatic fenestration. This procedure has its advantages over other modalities in that the large size of the diaphragmatic opening protected by the polypropylene mesh allows free drainage of pleural collection into the peritoneal cavity and at the same time prevents herniation of the abdominal viscera into the thorax. We postulate a phenomenon of autotransfusion of this protein rich exudate through the omentum, serosal coverings of the viscera, and the entire peritoneal cavity per se. Unlike a pleuroperitoneal shunt [6], which gets blocked easily, the possibility of this large fenestrated opening getting blocked is minimal. The morbidity associated with repeated chest tube insertions and pleurodesis is also avoided.

In summary diaphragmatic fenestration proved dramatic in its relief of the effusion. It is cost effective in that it reduces an otherwise prolonged hospital stay and the associated morbidity. It could be considered as a treatment option in post-Fontan patients with significant pleural effusions for whom conventional modalities of treating these effusions have failed.

	References

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1. deVivie E.R., Ruschewski W., Koveker G., Risch D., Weber H., Beuren A.J. Fontan procedure: indication and clinical results. Thorac Cardiovasc Surg 1981;29:348-354.[Medline]
2. Behrendt D.M., Rosenthal A. Cardiovascular status after repair by Fontan procedure. Ann Thorac Surg 1980;29:322-330.[Abstract/Free Full Text]
3. Airan B., Sharma R., Choudhary S.K., et al. Univentricular repair: is routine fenestration justified?. Ann Thorac Surg 2000;69:1900-1906.[Abstract/Free Full Text]
4. Kreutzer G.O., Vargas F.J., Schlichter A.J., et al. Atriopulmonary anastomosis. J Thorac Cardiovasc Surg 1982;83:427-436.[Abstract]
5. Rothman A., Mayer J.E., Freed M.D. Treatment of chronic pleural effusions after the Fontan procedure with prednisolone. Am J Cardiol 1987;60:408-409.[Medline]
6. Reich H., Beattie E.J., Harvey J.C. Pleuroperitoneal shunt for malignant pleural effusions: a one-year experience. Semin Surg Oncol 1993;9:160-162.[Medline]

This article has been cited by other articles:

				S. Talwar, S. K. Choudhary, S. B. Mukkannavar, and B. Airan Diaphragmatic fenestration for resistant pleural effusions after the Fontan operation J. Thorac. Cardiovasc. Surg., January 1, 2012; 143(1): 244 - 245. [Full Text] [PDF]

				S. Talwar, S. K. Choudhary, and B. Airan Diaphragmatic Fenestration for Resistant Chlyothorax Ann. Thorac. Surg., August 1, 2006; 82(2): 767 - 768. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Rajesh Sharma Shiv Kumar Choudhary Anil Bhan Panangipalli Venugopal Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Durairaj, M. Articles by Venugopal, P. Search for Related Content PubMed PubMed Citation Articles by Durairaj, M. Articles by Venugopal, P. Related Collections Diaphragm