Ann Thorac Surg 2000;70:574
© 2000 The Society of Thoracic Surgeons
Invited commentary
Invited commentary
Marshall L. Jacobs, MD
Section of Cardiothoracic Surgery, St. Christopher’s Hospital for Children, Erie Ave at Front St, Philadelphia, PA 19134–1095, USA
Invited commentary
Doctor Van Arsdell and colleagues have provided an interesting and important description of the evolution of treatment strategies that appear to have been associated with improved outcomes from Fontan’s operation. It is based upon a unique construct, wherein the 100 consecutive patients studied included 50 patients on either side of the inflection point of a graph plotting date of operation against early mortality. The authors do not suggest that they undertook a programmatic change in treatment protocols at the time corresponding to that inflection point. Rather, the analysis asks the question "What is it that we are doing differently (now that we’re doing so well), as compared to what we did in the bad old days?" Sorting through a great deal of carefully presented data, one finds the answer. (1) More patients are undergoing completion Fontan procedures, having previously undergone superior cavopulmonary anastomoses and (2) patients are spending less time on cardiopulmonary bypass. The second observation may be a direct consequence of the first. A completion Fontan procedure is a technically straight forward exercise, whether accomplished by lateral atrial tunnel or by extracardiac conduit. And if all other anatomic issues such as pulmonary artery distortion, systemic ventricular outflow obstruction, and atrioventricular valve dysfunction are addressed at the time of a prior cavopulmonary anastomosis, then the completion Fontan is not only a less time consuming procedure, but as importantly it is done on a heart with a healthier, less burdened myocardium.
To emphasize the two principle significant points in the analysis is not to discredit the authors’ enthusiasm for their current treatment protocols: single dose magnesium cardioplegia, baffle fenestration, institution of inotropic support in the operating room, hemo-concentration by ultra filtration and early extubation. All of the features of a successful integrated strategy must be considered important. Rather, it is the opinion of this reviewer that the experience of Dr Van Arsdell and his colleagues serves most importantly to further support the contemporary shift in emphasis from selection for Fontan’s procedure to preparationfor Fontan’s procedure. After judicious palliation of infant patients with single ventricle anomalies, early removal of the volume load from the systemic ventricle, and elimination of correctable hemodynamic burdens prior to the performance of Fontan’s operation renders the completion Fontan a straight forward technical exercise that can be accomplished with a brief period (or no period) of myocardial ischemia on a heart whose systolic and diastolic properties have been optimized. Like the Toronto group, we must each continue to refine our global approach to the single ventricle patient. At the same time, let’s not overlook what is fundamentally different about what we do now from what we did in the bad old days.
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Interventions associated with minimal Fontan mortality
- Glen S. Van Arsdell, Brian W. McCrindle, Kathleen D. Einarson, Kyong-Jin Lee, Elizabeth Oag, Christopher A. Caldarone, and William G. Williams
Ann. Thorac. Surg. 2000 70: 568-574.
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