CLINICAL-RESULTS OF THE STAGED FONTAN PROCEDURE IN HIGH-RISK PATIENTS

Background. For high-risk Fontan candidates, the introduction of a bid irectional Glenn shunt before total cavopulmonary connection (a two-st aged strategy) may extend the indications for the Fontan procedure. Th e clinical results of the two-staged and one-staged Fontan procedure w ere thus reviewed and compared. Methods. Between November 1991 and Jul y 1996, the two-staged strategy was performed in 40 high-risk Fontan c andidates with a mean interval of 17.2 months after introducing the bi directional Glenn shunt (staged group). We considered a young age (<2 years), high mean pulmonary arterial pressure (greater than or equal t o 20 mm Hg), high pulmonary vascular resistance (greater than or equal to 3 Wood units), small pulmonary artery (Nakata index <200 mm(2)/m(2 )), atrioventricular valve incompetence (greater than or equal to mode rate), distortion of pulmonary artery, anomalous pulmonary venous retu rn, and poor ventricular function as risk factors for the successful c ompletion of Fontan circulation. During the same period, 68 patients u nderwent the modified Fontan procedure in a one-step fashion (primary group). Results. In the staged group after the bidirectional Glenn shu nt, the mean pulmonary arterial pressure and ventricular end-diastolic pressure were both found to have decreased significantly to the same level as those in the primary group, whereas the pulmonary artery demo nstrated a significantly smaller size than that in the primary group. Operative morbidity was similar in both groups. Operative mortality wa s also similar and low in both groups (1.5% in the primary group and 0 % in the staged group). Conclusions. A bidirectional Glenn shunt was f ound to be a useful interim palliation in high-risk Fontan candidates. This two-staged strategy may extend the operative indications for the Fontan procedure. (C) 1998 by The Society of Thoracic Surgeons.