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The Annals of Thoracic Surgery, Vol 52, 1084-1094, Copyright © 1991 by The Society of Thoracic Surgeons
H Laks, JM Pearl, GS Haas, DC Drinkwater, E Milgalter, JM Jarmakani, J Isabel- Jones, BL George and RG Williams
Systemic venous hypertension after the Fontan procedure is a major cause of
mortality and morbidity, accounting for 11 of 16 deaths in our series of
228 Fontan procedures. A partial Fontan with a residual atrial septal
defect (ASD) would allow controlled right-to-left shunting to reduce venous
pressure and improve cardiac output while maintaining a reduced but
acceptable arterial oxygen saturation. This allows complete or graded
closure of the ASD after the discontinuation of cardiopulmonary bypass in
the operating room or at any time in the postoperative period by exposing
the snare under local anesthesia. From 1987 to 1990, 36 patients undergoing
the modified Fontan procedure had placement of an adjustable interatrial
communication. Indications for placement of an adjustable ASD included
increased pulmonary artery pressures, increased pulmonary vascular
resistance, reactive airway disease, previously increased or unknown
pulmonary vascular resistance, small pulmonary arteries, and borderline
ventricular function. Fourteen patients had the adjustable ASD closed at
the time of operation, 8 patients underwent narrowing, and 12 underwent
closure of the ASD in the postoperative period. Eight patients were
discharged with the ASD partially open, and 2 patients underwent delayed
closure. The partial Fontan with an adjustable ASD may increase the safety
of the Fontan procedure for high-risk groups such as those with increased
pulmonary vascular resistance, pulmonary hypertension, and impaired left
ventricular function and for infants, who tolerate venous hypertension
poorly. The ability to adjust the ASD in stages depending on the
hemodynamic response increases flexibility and safety.
ARTICLES
Partial Fontan: advantages of an adjustable interatrial communication
Department of Surgery, University of California, Los Angeles.
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