Importance of acquired systemic-to-pulmonary collaterals in the Fontan operation.
BACKGROUND
Children with chronic cyanotic heart disease often develop systemic-to-pulmonary collateral arteries that can be deleterious at the time of a Fontan procedure due to excessive pulmonary blood flow. We therefore occlude all significant collaterals during cardiac catheterization.


METHODS
From June 1993 to May 1998, 93 children aged 1.5 to 15.8 years (median 2.5 years) underwent a fenestrated lateral tunnel Fontan procedure. Eighty-nine (96%) had a previous bidirectional Glenn anastomosis, including 31 (33%) with a Norwood procedure.


RESULTS
Preoperatively, 33 children (35%) required occlusion of 1 to 11 (mean 3.6) collateral vessels. Two of the three perioperative deaths (operative survival 97%) were due to excessive pulmonary blood flow from unrecognized collaterals in one and uncontrollable collaterals in the other. Postoperatively, 19 children (20%) required coil occlusion of 1 to 21 (mean 5.6) collaterals for elevated pulmonary artery pressures, heart failure, or prolonged chest tube drainage. Duration of inotropic support, postoperative ventilation, intensive care unit stay, and postoperative hospitalization were all significantly longer in the patients who had postoperative occlusion of collaterals. On follow-up of 2 to 67 months (mean 35 months), there have been four late deaths (two infections, two heart failures); 6 patients underwent successful cardiac transplantation for refractory heart failure. All 8 patients with ventricular failure required occlusion of significant collaterals postoperatively.


CONCLUSIONS
Hemodynamically significant collaterals are not uncommon in Fontan candidates, and aggressive control can result in good operative and medium-term survival. After the Fontan, significant collaterals may be a marker for eventual cardiac failure because 8 of 18 patients requiring postoperative coils went on to transplantation or died of heart failure.
Kanter
K R
KR
Division of Cardio-Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia 30322, USA. kkanter@emory.org
Vincent
R N
RN
Raviele
A A
AA
D000293:Adolescent; D006328:Cardiac Catheterization; D002316:Cardiotonic Agents / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D003097:Collateral Circulation; D004621:Embolization, Therapeutic; D018729:Fontan Procedure / Q000401:mortality; D006330:Heart Defects, Congenital / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D007223:Infant; D007902:Length of Stay; D011182:Postoperative Care; D011300:Preoperative Care; D011652:Pulmonary Circulation; D012121:Respiration, Artificial; D015996:Survival Rate
D002316:Cardiotonic Agents