Current management of late failure after classic Fontan modifications: Fontan conversion.

BACKGROUND: Re-establishment of Fontan circulation by eliminating the drawbacks of classic Fontan modifications has been proposed recently to improve the functional class and quality of life of patients with failed Fontan circulation. METHODS: Five patients underwent extracardiac and lateral tunnel Fontan conversion due to failure of the Fontan circulation, after classic Fontan modifications. All of the patients were female and mean age was 10.2 +/- 2.2 years (range: 8-14 years). Previous Fontan modifications were atrio-pulmonary anastomosis in 3 and Kawashima operation in 2 patients. Time to re-operation for Fontan conversion was 6 +/- 1.5 years (range: 4-8 years). Indications for re-operation were right heart failure, right atrial dilatation, and intractable atrial arrhythmias in patients with previous atrio-pulmonary anastomosis, progressive hypoxia and exercise intolerance in patients with previous Kawashima operation due to pulmonary arteriovenous fistulas. Previous atrio-pulmonary anastomoses were converted to intra-atrial or lateral tunnel Fontan operation with modified right atrial Maze procedure. Extracardiac Fontan completion was carried out after previous Kawashima operations by redirection of hepatic veins to the lungs. RESULTS: There was no mortality and no major morbidity. All patients were discharged from the hospital in good condition and in sinus rhythm. No prolonged or recurrent effusions were observed. On follow-up, all patients were in sinus rhythm and had NYHA class I functional capacity. In two Kawashima patients, SpO(2) gradually increased from 60 % to 90 % six months after the operation. DISCUSSION: We suggest that Fontan conversion should be considered in patients with previous atrio-pulmonary anastomosis, when right atrial dilatation or intractable atrial arrhythmias with deteriorating functional status develops. Redirection of hepatic venous flow to lungs induces regression of pulmonary arteriovenous fistulas and improves arterial saturation in patients with previous Kawashima operation.

Early results of extracardiac fontan procedure with autologous pericardial tube conduit.

BACKGROUND: Different types of conduits are used for extracardiac Fontan procedure. The use of autologous pericardial tube as an alternative conduit for connecting the inferior vena cava to the pulmonary artery is investigated. METHODS: We performed 25 extracardiac Fontan procedures by using pericardial tube between June 2000 and October 2003. Fifteen patients were male. Mean age and weight were 7.6 +/- 4.9 years (range 3 to 24 years) and 22.8 +/- 10.4 kg (range 12 - 50 kg), respectively. RESULTS: All patients survived after extracardiac Fontan procedure. Prolonged chest tube drainage (> 7 days) was required in 9 (36 %) patients. Follow-up was complete and mean follow-up was 24.6 +/- 11.5 months (1 - 39 months). One patient died 3 months postoperatively. Routine serial postoperative echocardiographic examinations in all patients and magnetic resonance angiography in 6 patients with suspect flow patterns in echocardiography did not reveal any problems with the Fontan circuit. CONCLUSIONS: Fresh autologous pericardial tube conduit is a suitable and safe alternative for extracardiac Fontan procedures. Major advantages are availability, no cost, easy handling and hemostasis, low risk of thrombosis and emboli, and growth potential.

Pericardial collar modification for Ross procedure.

Although the surgical technique of the Ross operation has been improved over the years, there are still some technical difficulties: (1) The possibility of damage to first septal artery during harvesting and reconstruction of right ventricular outflow tract (RVOT). (2) Weak posterior anastomotic area during RVOT reconstruction. (3) Persistent bleeding from septal dissection site of pulmonary autograft. To deal with these difficulties, we used a 1-cm wide pericardial strip (pericardial collar) which was sutured to epicardium at the posterior and septal edge of the RVOT. The conduit used for the reconstruction of pulmonary outflow was then sutured to this pericardial strip at the posterior part of the anastomosis. We found this technique very useful to create a safe and strong margin for the posterior suture line. Persistent bleeding from septal dissection site can be also avoided using this modification by diverting the bleeding site into the right ventricular cavity.

Thoracic left kidney: a differential diagnostic dilemma for thoracic surgeons.

We report a case of left thoracic kidney that was identified after a detailed workup for a left thoracic mass that appeared on a routine chest roentgenogram of a young adult. Intravenous pyelography and angiography clearly identified this rare anomaly. Anatomical features and clinical implications of this condition are presented.

Early and moderate long-term results of a new surgical technique for repair of aortic coarctation.

OBJECTIVE: From June 1987 to September 1995, 53 patients underwent a new technique of coarctation repair. This technique consists of complete mobilization of the left subclavian artery so that it can be pulled down as far as possible. METHOD: After all the necessary clamping, the anterior wall of the aorta is incised longitudinally beginning on the anterior wall of the left subclavian artery and extending distally to the descending aorta 1-2 cm past the coarctation. The left subclavian artery is pulled down so that the proximal end of the incision can reach the distal end. Then, this longitudinal incision is sutured transversely with 5/0 or 6/0 polydioxanone and continuous technique, enlarging the coarctation site and also preserving the blood flow to the left upper limb. The ages of the patients ranged from 16 days to 20 years (mean 3.7 years). Thirty patients were younger than 1 year old. One patient (1.9%) died postoperatively due to persistent pulmonary hypertension. RESULTS: There was no pressure gradient perioperatively through the coarctation site after the repair. The mean follow-up was 34.4 +/- 27.5 months (range 1-99 months). All patients but one were in class I effort capacity (NYHA). Doppler echocardiographic studies were performed in 45 patients postoperatively. There was no restenosis or aneurysm formation at the coarctation site and the mean pressure gradients were between 19.8 +/- 16.2 mmHg. CONCLUSION: The authors experience indicates that this technique could be a good alternative to the subclavian flap aortoplasty because of the preservation of blood flow to the left arm.