FONTAN FENESTRATION CLOSURE IN THE CATHETERIZATION LABORATORY - ECHOCARDIOGRAPHIC EVALUATION OF RESIDUAL RIGHT-TO-LEFT SHUNTS

The Fontan procedure has become the preferred form of palliation for u niventricular hearts.(1-3) The morbidity and mortality of the Fontan p rocedure often results from high pulmonary vascular resistance and dec reased ventricular function in the postoperative period.(4,5) These fi ndings are often transient and resolve with time after surgery. The id ea of a fenestrated Fontan was conceived as a solution to these clinic al problems in the postoperative period. The fenestration allows for r ight to left shunting during states of high pulmonary vascular resista nce and decreased pulmonary blood now, allowing for maintenance of car diac output at the expense of systemic arterial oxygen saturation, The fenestration also decompresses the atria, decreasing the incidence an d duration of pleural effusions in the postoperative period, thereby d ecreasing morbidity and length of stay after the Fontan procedure.(6) The fenestration can then be closed when hemodynamics are more favorab le, i.e., lower pulmonary artery pressure and pulmonary vascular resis tance and improved ventricular function. At our institution, a fenestr ation is created in virtually all patients undergoing Fontan procedure , incorporating a snare closure device as first,described by Laks et a l.(7) The fenestration is then closed in the catheterization laborator y under general anesthesia on average 6 to 12 months after the Fontan procedure. Biplane/multiplane transesophageal echocardiography (TEE) i s performed during the procedure to monitor closure of the fenestratio n. This study assesses the success rate of fenestration closure in the catheterization laboratory, and evaluates the incidence of residual r ight to left shunts after Fontan fenestration closure.