Ann Thorac Surg 2001;71:76-77
© 2001 The Society of Thoracic Surgeons
Invited commentary: original article: cardiovascular
Invited commentary
Richard D. Mainwaring, MDa
a Nemours Cardiac Center, A. I. Dupont Hospital for Children, PO Box 269, 1600 Rockland Rd, Wilmington, DE 19899, USA
e-mail: mainwar{at}nemours.org
The authors describe their experience with 33 patients in whom they performed an extracardiac Fontan procedure. The hospital mortality was 6% and there was no late mortality, with a median follow-up of 16.5 months. These results indicate the feasibility of this approach; however, the authors do not answer the question that they propose in their introduction: whether extracardiac Fontan will have any real long-term advantages.
It is evident that there are currently a variety of philosophical approaches to the management of single ventricle. Current controversies are numerous and include the timing of bidirectional Glenn and Fontan procedures, the ideal interval between those operations, the type of Fontan, the role of fenestrations, and the importance of pulmonary artery size and aortopulmonary collaterals. Ultimately, if we are to determine the best management strategy for children born with single ventricle, we will need to address a three-part question. First, how do we achieve the highest success rate for the procedures themselves? Second, how do we achieve the highest long-term survival rates? And third, how do we achieve the best quality of life for these patients, including maximizing cognitive potential while minimizing the complications of arrhythmias, thromboembolic events, and the need for long-term medications and subsequent procedures?
The answer to the first question is becoming rather apparent, that is, the results of the Fontan procedure have improved so dramatically over the past decade using a host of different techniques that it will be difficult to prove an advantage or disadvantage henceforth. Although the authors of the current manuscript should be congratulated for their excellent results, these results have been equaled by others using alternative techniques. The issue of which management strategy will provide the best long-term survival has not been satisfactorily answered and probably will not be for some time. It can only be hoped that all of the strategies will have long-term outcomes similar to the actuarial survival curves that were published for the highly select group of tricuspid atresia patients. Assuming that all of the diverse strategies result in high rates of both short- and long-term survival, the final arbiter will be quality-of-life issues. It has been only in the last 5 years that many of these issues have been addressed in any substantive way. It has become clear from these studies that not all of the survivors are as perfect as we would like. In the final analysis, the only way to demonstrate whether one of these strategies has any "real advantages" will be to provide long-term follow-up with careful analysis of these quality-of-life issues.
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Early experience with extracardiac Fontan operation
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Ann. Thorac. Surg. 2001 71: 71-76.
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