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Ann Thorac Surg 2004;78:2210-2211
© 2004 The Society of Thoracic Surgeons

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Correspondence

Fenestration in Extracardiac-Conduit Fontan Operation

Cardiochirurgia Pediatrica, Istituto Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese (Mi), Italy

alegia{at}hotmail.com

To the Editor:

We read with interest the article by Kreutzer and colleagues [1] on a fenestration technique for the extracardiac Fontan operation. The authors used a pericardial skirt to anastomose the proximal end of the inferior vena cava (IVC) to a 4.5-mm hole in the extracardiac conduit. They presented the advantages of this technique and possible complications of alternative technical solutions proposed in the literature [2, 3].

Since January 2000, we have used a simpler technique in 12 patients. We avoid femoral vein cannulation and cannulate the aorta, the innominate vein, and the IVC. After interposition of a polytetrafluoroethylene (PTFE) extracardiac conduit between the IVC and the right pulmonary artery (extracardiac Fontan operation), a 4.5-mm orifice is made with a punch in the Gore-Tex conduit facing the right atrium (RA). The RA is opened and anastomosed to the wall of the Gore-Tex conduit around the 4.5-mm orifice with a running suture and a 0.5-cm margin. The 4.5-mm hole is not included in the running suture. When an intraatrial procedure (eg, atrioventricular valve repair, surgical treatment of atrial fibrillation) is needed, the fenestration is made during aortic cross-clamping. Otherwise, the fenestration is produced on the beating heart with the help of a spoon-type clamp positioned on the lateral wall of the RA. With this very simple fenestration technique, we avoid the use of a small PTFE conduit that is prone to develop thrombosis and become obstructed. The right atrial (RA) wall is sutured around the fenestration with a 0.5-cm margin; this leaves the conduit hole free from suture and reduces the risk of obstruction resulting from the different thicknesses of the RA wall and the PFTE conduit.

Kreutzer and co-authors allege that their technique is nonarrhythmogenic because the RA is not incised. We believe that a small RA incision does not increase the risk of arrhythmia. Arrhythmias in these patients are related to RA enlargement; often these patients have had previous multiple atriotomies, have enlarged atria, and are already experiencing atrial fibrillation, atrial reentry tachycardia, or both.

Our technique is very simple and does not need prosthetic material (conduit, patch). The fenestration can easily be closed by interventional catheterization. A transcatheter ablation, through the fenestration, was successfully performed for recurrent atrial fibrillation in 1 of our patients 3 months after the fontan operation. The fenestration is still patent in all patients at a mean follow-up of 14 months.

References

1. Kreutzer C, Schlichter AJ, Simon JL, Conejeros Parodi WM, Blunda C, Kreutzer GO. A new method for reliable fenestration in extracardiac conduit Fontan operations. Ann Thorac Surg. 2003;75:1657–1659[Abstract/Free Full Text]
2. Marcelletti CF, Iorio FS, Abella RF. Late results of extracardiac Fontan repair. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 1999;2:131–142[Medline]
3. Petrossian E, Reddy VM, McElhinney DB, et al. Early results of the extracardiac conduit Fontan operation. J Thorac Cardiovasc Surg. 1999;117:688–696[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 Author home page(s): Alessandro Giamberti Alessandro Frigiola Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Giamberti, A. Articles by Frigiola, A. Search for Related Content PubMed Articles by Giamberti, A. Articles by Frigiola, A. Related Collections Congenital - cyanotic Related Article