Experience of fontan surgery Pak Armed Forces Med J 2011; 61 (2): 160-63

EXPERIENCE OF FONTAN SURGERY AT ARMED FORCES INSTITUTE OF

CARDIOLOGY /NATIONAL INSTITUTE OF HEART DISEASES (AFIC-NIHD)
Syed Shahid Nafees Zaidi, Kamal Saleem, Inamullah Khan, Nausheen Bakht, Iftikhar Ahmed
Armed Forces institute of Cardiology Rawalpindi

ABSTRACT
Objective: To assess the overall outcome and success of Fontan surgery at our institute.
Place and Duration of study: AFIC-NIHD Rawalpindi. 01 September 2005 to 31 March 2010.
Patients and Methods: For his re rospec i e s d , ins i e s cardiac surgery database was used.
Patients of single ventricle physiology, who had normal Left Ventricular End-diastolic Pressure and
pulmonary artery pressures, were included. Data was analyzed using SPSS version 16.
Results: A total of 34 Fontan procedures were done. The mean age at operation was 4.83±1.37 years.
There were 22(64.7%) males and 12(35.3%) females. Twenty five (73.5%) had a staged Fontan
(s ccessf l pre io s Bidirec ional Glenn s sh n , BDG). Nine (26.5%) were primary Fontan
procedures (no successf l pre io s Bidirec ional Glenn s sh n , BDG). Thirty two (94.8%) were
Extra Cardiac Conduit Fontan (ECCF) and 2(5.8%) were Intra Cardiac Fontan. Mean Bypass time
was 132.65±48.44 minutes. Aorta was cross clamped in intracardiac Fontan and its mean time was
43.31±5.85minutes. Fenestration was employed in 14(41.2%) patients. Mean pre-operative oxygen
saturations were 77.41±10.27%, which significantly increased to 93.94± 3.96 % post-operatively
(p<0.001). In-hospital mortality was 2(5.8 %).
Conclusion: Fontan surgery has acceptable morbidity and mortality in our set up.
Keywords: Birectional Glenns Shunt, Fontan, Single ventricle.

INTRODUCTION (LTF), E ra-Cardiac Cond i Fon an (ECCF)

Single ventricle is a group of congenital and In racardiac Fon an . In LTF, blood in he
heart defects differing from each other with a inferior vena cava is diverted to pulmonary
common feature of a single ventricle of circulation by anastomosing a small length of
adequate function and size1. intra-atrial Gore-Tex conduit to Bidirectional
Glenns Shunt and clamping of aorta is
These patients undergo reconstructive
required6,7 . In ECCF, the pulmonary artery and
surgery in stages2. This eventually culminates inferior vena cava are anastomosed by sand
into the final stage of palliation called total wiching a Gore-Tex conduit of age-appropriate
cavo-pulmonary anastomosis (TCPC) or the size and in this procedure clamping of aorta is
Fontan procedure3. not required. Intracardiac Fontan also utilize
There are two types of Fontan procedures intra-atrial conduit to deliver systemic venous
depending upon whether a previous blood flow to Pulmonary artery.
Bidirectional Glenns Shunt (BDG) is, or is not In majority of the patients, staged Fontan
done. A patient in whom a previous BDG is not procedure is done. However, selection of a
undertaken and Fontan procedure is directly par ic lar s rgical proced re is he s rgeon s
performed is called a direc /primar Fon an . decision and it varies from case to case8.
In the second type of procedure, a BDG is
performed previously and the Fontan Most Fontans do not function efficiently
beyond 30 to 40 years. However, improvements
procedure is called staged Fontan4,5.
in surgical technique and medical care
Currently, a primary or staged Fontan may increase this age significantly9.
operation entails three different technical
proced res. These are La eral T nnel Fon an The present study highlights the overall
outcome and success of the procedure at our
Correspondence: Lt Col Syed Shahid Nafees Zaidi, institute. This research work has significance as
Classified Surgeon, AFIC/NIHD Rawalpindi the authors could not find any published work
Email: [email protected] on the subject, from Pakistan.
Received: 22July 2010; Accepted: 17 Aug 2010

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Experience of fontan surgery Pak Armed Forces Med J 2011; 61 (2): 160-63

PATIENTS AND METHODS were 12(35.3%). Demographics are shown in

This retrospective study was conducted at Table. Distribution of cardiac anatomic
Armed Forces Institute of Cardiology-National diagnosis is displayed in Figure.
Institute of Heart Disease (AFIC-NIHD) Twenty five (73.5%) patients had staged
Rawalpindi Pakistan. Fontan, of these Intra-cardiac were 2 and ECCF
In 2005, AFIC-NIHD collaborated with the were 23. Patients who underwent primary
In erna ional Children s Hear Fo nda ion, Fontan were 9(26.4%), and all of these were
(ICHF) USA for the up gradation of its ECCF. Mean Bypass time was 132.65 ± 48.44
congenital surgery program. Today AFIC- minutes. Mean aortic clamp time was 43.31 ±
NIHD is the only hospital of Pakistan where 5.85 minutes. In ECCF the mean size of Gore-
Fontan procedure is successfully and regularly Tex conduit was 22.4 ± 2.39 mm.
done. Fenestration was done in 14(41.2%)
Our study subjects were patients operated patients. Mean pre-operative oxygen
for single ventricle physiology, in our institute saturations were 77.41 ± 10.27 %, which
significantly increased to 93.94 ± 6% post-
between 01 September 2005 and 31 March 2010.
operatively (p<0.001). Mean ventilation time
The s d ins r men as he ins i e s was 4.76 ± 3.37 hours. Mean Fontan pressure
cardiac surgery database. Our variables was 15mm Hg. Ten (29.4%) patients were re-
included age, gender, weight, height, disease opened; 6 for post-operative bleeding, 1 for
pattern, staged or primary Fontan (previous or graft revision and 3 for blocked pleural drains
no BDG)s, bypass time, aortic clamp time, pre along with pacing wires readjustment.
and post-operative oxygen saturation, Intra- Inotropes were used in 22(65%) of patients.
cardiac Fontan or Extra cardiac conduit Fontan Pleural drainage continued for 6.21 ±1.9 days.
(ECCF) done, conduit size, fenestration, Sinus rhythm was present in 27(79.4%) patients;
ventilation time, Fontan pressures 24 hours in 4 cases it was AV nodal while in 3 patients
post-operatively, cardiac rhythm, Sildenafil use, atrial fibrillation was present. Tab Sildenafil
reopening done, graft thrombosis, duration of was started per-operatively and continued post-
inotropes, duration of pleural drainage, ICU operatively in 7(20.65%) patients. 494.12±94.06
stay, in-hospital mortality and 6 months post- ml blood products were used to
operative mortality. haemodynamically stabilize the patients. Mean
Patients with normal Left Ventricular End- ICU stay was 7.21±1.9 days. One patient
diastolic Pressure and pulmonary artery developed turbulent flow due to partial
pressures were included in the study. Cardiac thrombus formation on IVC side of ECCF. He
catheterization was performed in all patients. was monitored with serial 2D-Echo and treated
Statistical Analysis with IV heparin. Total In- hospital mortality
Data was analyzed using SPSS version 16. was 2(5.88 %). One death occurred 6 months
For quantitative variables, mean and standard post operatively due to coagulation disorder
deviation (SD) and for qualitative variables, and massive upper GI bleeding.
frequencies along with percentage were used Legend: Complete AVSD=Complete atrio
for description of variables. Independent ventricular septal defect; DILV=Double Inlet
sample s -test was used for comparison of Left Ventricle; DORV=Double Outlet Right
quantitative variables while chi-square test was Ventricle; TGA+DILV=Transposition of great
used for comparison of qualitative variables arteries and double inlet left ventricle;
between different groups. A two-tailed p<0.05 TGA+DORV= Transposition of great arteries
was considered statistically significant. and double outlet Right ventricle; PUL
RESULTS ARESIA=Pulmonary atresia
In this four and a half year study period, a DISCUSSION
total of 34 patients underwent Fontan Thirty four patients who underwent
procedure. Males were 22(64.7%) and females Fontan operation had a mean age of 4.8 years.

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Experience of fontan surgery Pak Armed Forces Med J 2011; 61 (2): 160-63
Table: Demographics of patients
less in fenestrated Fontan due to mixing of
blood at atrial level.

Maximum
Minimum
Variables SD Mean ventilation time of 4 hours in our

Mean
study is at par with contemporary studies 16.
Early extubation enhances the haemodynamic
Age( Years) 3.0 7.0 4.831 1.376 stability of our Fontan patients post operatively
Weight ( Kg) 9 24 14.62 3.681 and improves the patient outcome.
Height (CM) 80 113 100.73 8.795 Mean Fontan pressures of 15mmHg in our
study is also the same as in other studies17.
Disease
COMPLET AVSD
DILV
Seven patients who had > 15mmHg
DORV
PUL ATRESIA
Fontan pressures were given Sildenafil per-
2.94%
14.71%
TGA+DILV
TGA+DORV
operatively, which was continued post-
Tricuspid atresia
operatively for 3 months. Similar results have
been reported by others18. Mean pleural
38.24% 2.94%

2.94%
drainage duration was slightly less than other
studies7,19. More blood products were used on
our patients due to more post-operative blood
loss and hence a higher re-opening rate.
29.41% Our re-opening rate of 29.4% is higher
8.82%
than others. A strong emphasis on effective
haemostatic techniques / protocols, optimum
chest physiotherapy, milking of pleural drains
will lead to an improvement of results15.
Figure: Distribution of disease pattern in all cases
of Fontan operation. Mean ICU stay of 7 days is more than what
others have reported7,19,20. . This is because the
Internationally, Fontan surgery is procedure is relatively new in our set-up and
undertaken at two years of age 1, 2, 3 . In our case, hope the ICU stay will decrease as more and
relatively late age surgery is due to late more volume of this procedure is done in the
reporting of patients4,5. future
Bypass time and aortic cross clamp time in One patient of ECCF, while in hospital,
our study was similar to other contemporary developed partial thrombosis of the inferior
studies8. vena cava side of the conduit and
Some researchers have reported good hepatomegaly. He was treated with
results without using heart lung machine,9 intravenous heparin and monitored with serial
however, we have used it in all of our cases. 2-D Echo. After treatment of 7 days his
condition improved, hepatomegaly regressed to
The mean size of Gortex tube graft near normal levels and he was later discharged.
anastomosed was 22.4 mm which is larger as Total in-hospital mortality of two patients
compared to other studies10,11,12. It is due to the (5.8%) is comparable with other studies4,7,19,21,22.
older age of our clientele.
There are some limitations to the present
In our study, fenestration was done in study. First this study was not a prospective,
41.2% cases but lesser percentages have been randomized study and second in more recent
quoted by other researches13,14. The mean size of patients, there is limited follow-up which may
fenestration (5.1mm), however, matches with lead to under estimation of long term morbidity
other studies15. and mortality. In addition,further evaluation of
Post-surgery oxygen saturation increased a large number of patients with long term
significantly (p-value <0.001). The increase was follow-up will be necessary.

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Experience of fontan surgery Pak Armed Forces Med J 2011; 61 (2): 160-63

CONCLUSION 8. Marcelletti C, Corno A, Giannico S, Marino B. inferior vena cava

pulmonary artery conduit. A new form of right heart bypass. J Thorac
Cardiovac Surg 1990; 100; 228-32.
Patients of single ventricle morphology
9. Ed Petrossian, MD , V. Mohan Reddy, MD, Kathryn K. Collins, MD,
undergo staged reconstructive surgery and Casey B. Culbertson, MD, Malcolm J. MacDonald, MD, John J.
usually the first stage is BDG except in few Lamberti, MD, The extracardiac conduit Fontan operation using
minimal approach extracorporeal circulation: Early and midterm
patients depending on their presentation, outcomes, J Thorac Cardiovasc Surg 2006;132:1054-63.
pulmonary artery band or modified Blalock- 10. Y. Ochiai, Y. Imoto, M. Sakamoto, A. Sese, M. Tsukuda, M. Watanabe,
Taussig shunt becomes the first stage. If BDG et al. Longitudinal growth of the autologous vessels above and below
the Gore-Tex graft after the extracardiac conduit Fontan procedure.
remains successful, they are offered Fontan Eur. J. Cardiothorac. Surg., 1, 2010; 37(5): 996-1001.
surgery. The need of the hour is to conduct
11. T. Nakano, H. Kado, T. Tachibana, K. Hinokiyama, A. Shiose, M.
further research into intracardiac Fontan, LTF Kajimoto, et al. Excellent Midterm Outcome of Extracardiac Conduit
and ECCF; fenestrated and non-fenestrated Total Cavopulmonary Connection: Results of 126 Cases. Ann. Thorac.
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striving to make them even better. Consecutive Patients. Ann. Thorac. Surg. 1, 2007; 84(3): 894 - 899.
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