Importance of acquired systemic-to-pulmonary collaterals in the fontan operation

Background. Children with chronic cyanotic heart disease often develop syst emic-to-pulmonary collateral arteries that can be deleterious at the time o f a Fontan procedure due to excessive pulmonary blood now. We therefore occ lude all significant collaterals during cardiac catheterization. Methods. From June 1993 to May 1998, 93 children aged 1.5 to 15.8 years (me dian 2.5 years) underwent a fenestrated lateral tunnel Fontan procedure. Ei ghty-nine (96%) had a previous bidirectional Glenn anastomosis, including 3 1 (33%) with a Norwood procedure. Results. Preoperatively, 33 children (35%) required occlusion of 1 to 11 (m ean 3.6) collateral vessels. Two of the three perioperative deaths (operati ve survival 97%) were due to excessive pulmonary blood now from unrecognize d collaterals in one and uncontrollable collaterals in the other. Postopera tively, 19 children (20%) required coil occlusion of 1 to 21 (mean 5.6) col laterals for elevated pulmonary artery pressures, heart failure, or prolong ed chest tube drainage. Duration of inotropic support, postoperative ventil ation, intensive care unit stay, and postoperative hospitalization were all significantly longer in the patients who had postoperative occlusion of co llaterals. On follow-up of 2 to 67 months (mean 35 months), there have been four late deaths (two infections, two heart failures); 6 patients underwen t successful cardiac transplantation for refractory heart failure. All 8 pa tients with ventricular failure required occlusion of significant collatera ls postoperatively. Conclusions. Hemodynamically significant collaterals are not uncommon in Fo ntan candidates, and aggressive control can result in good operative and me dium-term survival. After the Fontan, significant collaterals may be a mark er for eventual cardiac failure because 8 of 18 patients requiring postoper ative coils went on to transplantation or died of heart failure. (Ann Thora c Surg 1999;68:969-75) (C) 1999 by The Society of Thoracic Surgeons.