INTERMEDIATE RESULTS OF THE EXTRACARDIAC FONTAN PROCEDURE

Background. Fourteen children (ages 2 to 14 years) and 1 adult (32 yea rs) have undergone a modification of the Fontan procedure in which an extracardiac lateral tunnel or conduit is used in combination with sta ged or simultaneous bidirectional Glenn shunt(s). Methods. Extracardia c lateral tunnels (n = 9) were constructed using a polytetrafluoroethy lene patch (n = 7), pericardial patch (n = 1), or in situ pericardial nap (n 1). Extracardiac lateral conduits (n = 6) were constructed usin g nonvalved homografts (n = 2) or polytetrafluoroethylene tube grafts (n = 4). Fenestrations were created in 4 patients (2 each in extracard iac lateral tunnel and extracardiac lateral conduit patients). Aortic crossclamping was completely avoided in 12/15 patients (aortic cross-c lamping in 2 patients for atrial septal defect enlargement and 1 for D amus-Kaye-Stansel procedure). Results. There have been no operative de aths. Prolonged postoperative chest tube drainage (> 2 weeks) has been rare (n = 1). At follow-up (range, 6 to 54 months; mean, 27.5 months) , all patients are in New York Heart Association class I or II and rem ain in normal sinus rhythm. Late protein-losing enteropathy was seen i n 1 patient and was successfully treated by percutaneous creation of a stented fenestration from the extracardiac tunnel to the systemic atr ium. Late catheterizations reveal unobstructed extracardiac lateral tu nnel function and low pulmonary pressures (range, 11 to 13 mm Hg). Adv antages of the extracardiac Fontan include (1) avoidance of aortic cro ss-clamping in most patients, (2) the hemodynamic benefits of total ca vopulmonary connection, (3) avoidance of atriotomy and intraatrial sut ure lines, (4) preservation of sinus rhythm and no arrhtythmias at 2 y ear follow-up, (5) drainage of the coronary sinus to low pressure atri um, (6) allowance for early/late fenestrations, (7) prevention of baff le leaks and intraatrial obstruction, and (8) allowance for growth (tu nnel procedures only). Conclusions. We recommend this extracardiac pro cedure for all suitable patients undergoing surgical conversion to the Fontan circulation.