Extracardiac vs Intra-atrial Lateral Tunnel Fontan: Extracardiac is Better. No it s not: (They both have problems)
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1 Extracardiac vs Intra-atrial Lateral Tunnel Fontan: Extracardiac is Better No it s not: (They both have problems)
2 Why is it difficult to analyze outcomes after the Fontan procedure? Wide range of patient morphology Variable pre-fontan palliation Multiple technical modifications of Fontan procedure since 1970 First generation: Atrio-pulmonary Second generation: Lateral tunnel Third generation: Extra-cardiac conduit
3 Thorax 1971; 26:240
4 Fontan F, Kirklin JW, Fernandez G, Costa F, Naftel DC, Tritto F, Blackstone EH. Outcome after a perfect Fontan operation Circulation 1990;81: Use of a valved RA-PA conduit was an incremental risk factor for late death by multivariate analysis Left atrioventricular valve atresia
5 Patch RA Atrial Septum
6 Lateral Tunnel Fontan (Total Cavopulmonary Connection) Distal takedown of Blalock shunt w/ enlargement of arteriotomy Division of MPA Right atrial incision Division of SVC Jonas RA, Castaneda AR. J Cardiac Surg 1988; 3:91-96
7 Gortex baffle Lateral Tunnel Fontan (Total Cavopulmonary Connection)
8 Fenestrated Lateral Tunnel Fontan Aortic punch used to create fenestration Bridges ND et al, Circulation 1990; 82:
9 Hopkins RA, Armstrong BE, Serwer GA, Peterson RJ, Oldham HN Jr. Physiological rationale for a bidirectional cavopulmonary shunt. versatile complement to the Fontan principle. J Thorac Cardiovasc Surg 1985;90:391-8
10 SVC Bidirectional Glenn Shunt RPA LPA RA Bridges ND, Jonas RA et al., Bidirectional cavopulmonary anastomosis as interim palliation for high-risk Fontan candidates Circulation 1990; 82 (suppl IV) IV IVC
11 Lateral Tunnel After Bidirectional Glenn Shunt A. book) Atrial incision anterior to sinus node B.
12 Lateral Tunnel After Bidirectional Glenn Shunt C. D. E. F.
13 Hemi-Fontan Procedure
14 Alternative Hemi-Fontan procedure Brown et al Ann Thorac Surg 2010;89:556-62
15
16 Rodefeld, Huddleston et al J Thorac Cardiovasc Surg 1996; 111:
17 Rodefeld MD, Bromberg BI, Schuessler RB, Boineau JP, Cox JL, Huddleston CB. Atrial flutter after lateral tunnel construction in the modified Fontan operation: a canine model J Thorac Cardiovasc Surg 1996;111: Before suture line placement, no dog had inducible atrial flutter. After placement of the suture line, sustained atrial flutter was reproducibly induced in every dog.
18 Extracardiac Conduit Fontan Procedure Marcelletti et al, J Thorac Cardiovasc Surg 1990; 100:
19 J Thorac Cardiovasc Surg. 2001;121:28-41
20 Longterm Survival after Lateral Tunnel Fontan Survival [%] (220) (192) (171) (167) (102) Time [years]
21 Longterm Results after Lateral Tunnel Fontan: Freedom from New SVT 100 Freedom from new SVT [%] (212) (183) (160) (155) (59) Time [years]
22 Longterm Results after Lateral Tunnel Fontan: Freedom from Bradyarrhythmia Freedom from bradyarrhythmia [%] (207) (161) (130) (103) (59) Time [years]
23 Freedom from new SVT: 98% at 5 years ;95% at 10 years Freedom from bradyarrhythmia: 97% at 5 years; 96% at 10years Multivariable risk factors for development of supraventricular tachyarrhythmia included atrioventricular valve abnormalities (p = 0.02), and preoperative bradyarrhythmia (p = 0.01). Ann Thorac Surg 2010;89:556-62
24 Hirsch JC, Goldberg C, Bove EL, Salehian S, Lee T, Ohye R, Devaney EJ. Fontan operation in the current era: A 15- year single institution experience Ann Surg 2008; 248: % of 636 patients had the lateral tunnel Fontan We have preferred to do the lateral tunnel Fontan at the University of Michigan for a multitude of reasons.
25 Ann Thorac Surg 2007;83:622-9 Conclusions The EC and LT operation had comparable early and late mortality, readmission for chylous effusion, preservation of sinus rhythm,and frequency of all neurologic events. The more frequently fenestrated LT cohort used fewer resources.
26 Hakacova N, Lakomv AM, Kovacikova L. Arrhythmias after Fontan operation: comparison of lateral tunnel and extracardiac conduit J Electrocardiol 2008;41:173-7 Retrospective analysis of the incidence, types, and duration of rhythm disorders in 101 consecutive patients who received either LT (n = 60) or EC (n = 41) Extracardiac conduit as compared with LT does not provide superior outcomes related to the problem of early and 1- year onset arrhythmias
27 Ann Thorac Surg. 2003;76: From November 1995 through October 2002, 70 Fontan procedures were performed: 37 LT and 33 ECC. Conclusions The LT and ECC approaches had comparable early and midterm outcomes, including operative morbidity and mortality, postoperative hemodynamics, resource use, and mid-term survival and functional status ECC patients had a higher!!! incidence of sinus node dysfunction early after operation
28 Arrhythmia after Fontan Fiore et al 2007 Indiana/St. Louis Cohen et al 2000 CHOP Azakie et al 2009 Toronto Kumar et al 2003 South Carolina ECC Lateral tunnel P Non-sinus rhythm 15% Non-sinus rhythm 18% N.S. 13% 13% N.S. 7% 23% < % 15% 0.2 Hakacova et al 2008 Slovakia Early arrhythmia 52% 54% N.S.
29 Why is there a high incidence of arrhythmia with the extracardiac conduit Fontan? May be secondary to damage to the Crista terminalis, particularly if the procedure is done off pump.. Large atrial cuff
30 Extracardiac Conduit Fontan Procedure Marcelletti et al, J Thorac Cardiovasc Surg 1990; 100:
31 John Brown in Discussion of Lateral tunnel Fontan in the Current Era: Is it still a good option? Ann Thorac Surg 2010;89: We try to use a no-touch technique for the crista terminalis, the atriocaval junction and the blood supply to the SA node. That is a no man s land for us. You can t disturb those tissues and expect that the patient is going to remain in sinus rhythm
32 Zhao QY, Huang H, Tang YH, Wang X, Okello E, Liang JJ, Jiang H, Huang CX. Relationship between autonomic innervation in crista terminalis and atrial arrhythmia J Cardiovasc Electrophysiol 2009; 20: The higher densities of adrenergic nerve in the Crista Terminalis play an important role in the genesis of atrial arrhythmia.
33 Pleural Effusions and Hospital Stay Fiore et al 2007 Indiana/St. Louis Hirsch et al 2008 U Michigan Fu Song et al 2009 Giessen Kumar et al 2003 South Carolina Azakie et al 2001 Toronto ECC Lateral tunnel P Hospital stay (33% fenestration) Prolonged drainage 33% (35% fenestration) w/fenestration w/o fenestration 10 days 11 days (100% fenestration) 8 days 11 days (77% fenestration) Hospital stay (73% fenestration) Prolonged drainage 18% (100% fenestration) 8 days 12 days (100% fenestration) 9 days 13 days (85% fenestration) <
34 Why do many centers doing the extracardiac conduit suggest that a fenestration is not necessary? Because it s technically challenging to keep a fenestration open with a standard ECC Fontan
35
36 Summary of Advantages and Disadvantages ECC vs Lateral Tunnel ECC Technically simpler, more easily reproducible with variable patient morphology Minimizes atrial suture lines No atrial tissue at high pressure Difficult to fenestrate No catheter access to atrium No growth potential Avoids CPB + X-clamp Lateral tunnel Judgment required Heavier atrial suture burden Thin strip of atrial tissue at high pressure Easy to fenestrate Catheter access to atrium available Grows Short clamp time, CPB mandatory
37 Extracardiac conduit Fontan IS NOT better than the Intra-atrial Lateral Tunnel Fontan
38 Acknowledgements Medical illustrator Powerpoint creator Research Becky Dodson Laura Young TK Susheel Kumar MD
39 Why is it difficult to analyze risk factors for Fontan outcome? Wide range of patient morphology Variable pre-fontan palliation Multiple technical modifications of Fontan procedure since 1970 First generation: Atrio-pulmonary Second generation: Lateral tunnel Third generation: Extra-cardiac conduit Fourth generation: Intra/extracardiac conduit with fenestration
40 The Intra/Extracardiac Conduit Fenestrated Fontan Atrial incision avoids Sinus node Crista terminalis Sinus node artery
41 The Intra/Extracardiac Conduit Fenestrated Fontan Ring-supported Goretex conduit Goretex suture tacks atrial wall to conduit Fenestration in short intra-atrial segment
42 The Intra/Extracardiac Conduit Fenestrated Fontan
43 The Intra/Extracardic conduit Fontan
44 Results of Intra/Extracardiac Conduit: First 7 patients at Children s National Medical Center 6/7 patients in Sinus rhythm at latest follow-up, one with low atrial rhythm 2/7 patients had transient early sinus node dysfunction EP team have commented on markedly lower incidence of early post-op junctional rhythm relative to lateral tunnel
45 Conclusions The intra/extracardiac conduit combines the advantages of both the Extracardiac conduit and the Lateral Tunnel and has fewer of the disadvantages
46
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