The extracardiac conduit Fontan operation using minimal approach extracorporeal circulation: early and midterm outcomes.

OBJECTIVE: Our approach to the extracardiac conduit Fontan operation has evolved over time from full-pump, to partial-pump, to completely off-pump. This study is designed to report our overall experience with the extracardiac conduit Fontan operation and to evaluate the evolution in bypass technique on postoperative outcomes. METHODS: From September 1992 to April 2005, 285 patients, median age 4.5 years (1.4-44 years), median weight 16 kg (9.4-94 kg), underwent a primary extracardiac conduit Fontan procedure. Early and late outcomes were analyzed for the entire cohort and for 2 patient groups depending on whether an oxygenator was used in the bypass circuit (166 patients; 58%) or not (119 patients; 42%). RESULTS: Early failure (including death and takedown) occurred in 7 patients (2.5%). Prevalence of new early postoperative sinus node dysfunction necessitating a permanent pacemaker was 0.4%, and that of new tachyarrhythmias necessitating discharge home on a regimen of antiarrhythmia medications was 2.5%. Ten-year actuarial freedom from Fontan failure, new sinus node dysfunction necessitating a permanent pacemaker, and reoperation for conduit thrombosis or stenosis was 90%, 96%, and 98%, respectively. Fenestration rate was lower (P = .001) in the no-oxygenator group (8%) than in the oxygenator group (25%). Patients in the no-oxygenator group had lower intraoperative Fontan pressure (12.0 +/- 2.3 vs 13.5 +/- 2.4 mm Hg, P < .001), common atrial pressure (4.6 +/- 1.8 vs 5.3 +/- 1.8 mm Hg, P = .003), and transpulmonary gradient (7.5 +/- 2.1 vs 8.3 +/- 2.2 mm Hg, P = .013) than did the oxygenator group. CONCLUSIONS: The extracardiac conduit Fontan operation coupled with minimal use of extracorporeal circulation is associated with favorable intraoperative hemodynamics, low fenestration rate, minimal risk of thrombosis or stenosis, and minimal early and late rhythm disturbance.

Effects of psychotropic medications on the pediatric electrocardiogram and recommendations for monitoring.

Reports of sudden unexpected death in pediatric patients taking selected psychotropic drugs have raised the possibility of ventricular dysrhythmias as the cause of these deaths. The use of psychotropic drugs in the pediatric population has increased significantly in recent years with increasing reports of electrocardiogram abnormalities, particularly prolongation of the corrected QT interval. Many factors affect the susceptibility of the heart to conduction abnormalities and sudden ventricular dysrhythmias in pediatric patients taking psychotropic drugs. These complex relations include genetic predisposition, structural cardiac disease, drug-drug interactions, drug dosage, and drug metabolism and clearance. Many specific psychotropic drugs have been reported to prolong the QTc interval and increase the risk of ventricular dysrhythmias and sudden death. This article discusses the various factors that may influence the electrocardiogram in pediatric patients taking psychotropic drugs and recommendations for monitoring these patients.