**5. Results**

Management strategies in cases of functional single ventricle have come to a group of procedures where the goal is to obtain a ventricular pressure and volume close to normal. Our study demonstrated our experience in the management protocol of univentricular patients in total cavopulmonary connection (Fontan operation). As in other centers, the most commonly used technique has been the fenestrated, extra-cardiac Fontan, which in our study represent 58.9% of the total sample (30 patients) - Table No.1. The hospital stay was 13.6 days on average.


Table 1. Fontan type

256 Congenital Heart Disease – Selected Aspects

All patients were operated through a median sternotomy with extracorporeal circulation and moderate hypothermia. We used two techniques of total cavopulmonary anastomosis, according to anatomical characteristics of each patient. The technique I corresponds to the construction of an intracardiac lateral tunnel constructed with a patch of polytetrafluoroethylene (PTFE) sutured to the lateral aspect of the right atrium, thereby building a tunnel that diverts intracardiac blood from the inferior cava to the right pulmonary artery, thus completing total cavo-pulmonary connection. For these patients we routinely use aortic clamping and cardioplegia with blood. The technique II is interposition of a PTFE tube between the transected inferior cava and pulmonary artery, ipsilateral to the inferior cava vein, also completing total cavo-pulmonary connection. This is known as extracardiac Fontan. Use of aortic clamping and cardioplegia is optional according to surgeon's preference. Both techniques are performed with almost routine fenestration of 4 to 5 mm. In the technique I, a circular punch incision in the PTFE patch is made, so to communicate intracardiac lateral tunnel with atrial mass receiving the pulmonary venous return. In technique II, the fenestration is created by a similar punch incision in the lateral PTFE inner tube and a similar incision on the lateral aspect of the right atrium, proceeding

We included all patients with univentricular hearts who underwent Fontan operation. We reviewed the records of the patients included in the univentricular heart protocol and database service Congenital Cardiac Surgery Cardiovascular Clinic of Santa Maria de Medellin (Colombia), identifying all patients undergoing the Fontan operation with

**Monitoring.** All patients who survived the Fontan surgery underwent clinical and echocardiographic follow-up. We also obtained information about procedures performed after surgery, medication use and functional ability (classified according to New York Heart Association guidelines), interviewing parents and cardiologists caring for for each patient.

Management strategies in cases of functional single ventricle have come to a group of procedures where the goal is to obtain a ventricular pressure and volume close to normal. Our study demonstrated our experience in the management protocol of univentricular patients in total cavopulmonary connection (Fontan operation). As in other centers, the most commonly used technique has been the fenestrated, extra-cardiac Fontan, which in our study represent 58.9% of the total sample (30 patients) - Table No.1. The hospital stay was

**2. Surgical technique** 

**3. Type of study** 

**5. Results** 

13.6 days on average.

**4. Population and sample** 

to be anastomosed both holes as Luther-lateral (7.8).

Analytical study of cross-sectional, cohort analysis.

technique total cavopulmonary anastomosis between 1994 and 2010. We reviewed the medical records, operative reports and echocardiograms.


#### Table 2. Death

The number of patients who failed was a total of 8; the cause in 4 of them (50% of total deaths) was low output syndrome which was present in the first 72 hours postoperatively, and the remaining 4 patients died after 72 hours after Fontan. These patients had a progressive deterioration associated with symptoms and signs of heart failure, proteinlosing enteropathy, persistent chylothorax, affecting directly their functional status and no response to medical management. These data are shown in Table No. 3.


#### Table 3. Cause of death

The end result is shown in Table No. 4, where 47 of them (84%) were discharged and continued in a functional stage I 9n 82.1% of them (Table No. 5). One patient (1.8%) sample was transferred from the Cardiovascular Clinic to another facility outside the country.


Table 4. Cause of discharge

Fontan Surgery: Experience of One Cardiovacular Center 259

have been implemented for patients classically diagnosed with tricuspid atresia, but now with the increased survival of patients diagnosed with hypoplastic left heart syndrome, the question arises about the reduced ability of right ventricle to be able in time to support adequately the work of a single ventricle physiology to complete the process to the Fontan (3,17,18). This perception has not been recently supported (19.20). Mosca and colleagues show their results in 100 patients with Fontan performed between 1992 and 1998. They found no significant difference in the outcome compared to other types of single ventricle (21). Pizarro subsequently concluded that the Fontan can be performed safely in patients with SHIV making some modifications in surgical technique according to ventricular morphology, the mass ratio - volume and hemodynamic parameters, further suggests that Fontan surgery can be successful at earlier ages avoiding long exposure to hypoxia and risk

Our results regarding operative mortality and mid-term survival are comparable to those reported by other groups. In these studies, the mortality rate varied between 0 and 27% with an average of 10.5% and the 5-year survival varied between 81% and 93%, with an average

In relation to our surgical protocol in stages, 73.9% of patients had a bidirectional Glenn operation around 6 months of age, preparatory for the Fontan operation. The advantages of

Regarding the use of anticoagulation, we decided to keep our patients with oral anticoagulation for about 6 months with the objective of preventing thrombosis at the site of

Management strategies in cases of functional single ventricle have come to a group of procedures where the goal is to obtain a ventricular pressure and volume close to normal. This analytical cross-sectional, cohort analysis is meant to show expertise in the management protocol of univentricular patients by total cavopulmonary connection (Fontan operation.) in Cardiovascular Clinic Santa Maria in the city of Medellin. Based on this study we conclude that the Fontan operation is safe with a mortality rate comparable to previously published large series (14.3%); the results are independent of the type of ventricle and the hospital length of stay is short (average hospital stay of 13.9 days). Postoperatively, is that

[1] Pizarro Ch, Mroczek T, Gidding S, Murphy J, and Norwood W. Fontan Completion in

[3] Kreutzer G, Galindez E, Bono H, de Palma C, Laura JP. An operation for the correction

[2] Fontan F, Baudet E. Surgical repair of tricuspid atresia. Thorax 1971;26:240–8.

of tricuspid atresia. J Thorac Cardiovasc Surg 1973; 66: 613–21. [4] Andropoulus D, Stayer S, Russell I. Anesthesia for congenital heart disease 2010. [5] Anderson R, Pozzi M, Hutchinson S. Hypoplastic left heart syndrome 2005.

[7] Jonas R. Comprehensive surgical management of congenital heart disease 2004.

fenestration, after this period of time, we defined the need to close the fenestration.

This study determined that the average hospital stay was 13.9 days.

of paradoxical embolism (1).

this strategy have been previously described (24,25,26).

over 90% of patients were in functional class I - II.

[6] Lake C. Pediatric cardiac anesthesia 2005.

Infants. Ann Thorac Surg 2006; 81:2243–9.

[8] Nichols D. Critical heart disease in infants and children 2006.

of 87.5% (9,10,22, 23).

**7. Conclusions** 

**8. References** 


Table 5. Current functional class

Based on this study we conclude that the Fontan operation is a safe with a mortality rate comparable to that reported in previously published large series (Our series 14.3%), which is shown in the table No. 2. The Mayo Clinic experience, shows a overall mortality after Fontan, of 16%, but Many factors may have contributed to decreased early mortality after Fontan. Improved patient selection, younger age at time of operation, refinements in surgical techniques and postoperative management may all have had important roles.
