title: Fenestration during Fontan palliation: now the exception instead of the rule.
abstract: OBJECTIVE
  Fenestration during Fontan palliation has traditionally been used to decrease surgical morbidity and mortality, particularly in high-risk cases. Potential limitations include oxygen desaturation, risk of paradoxic embolism, and need for late intervention. Our practice has evolved away from routine fenestration with increased extracardiac conduit use. We reviewed our experience with Fontan palliation and retrospectively assessed outcomes with decreased fenestration.
  
  
  METHODS
  Between January 2002 and April 2008, 226 patients underwent primary Fontan palliation. Outcomes were assessed by hospital stay, chest drain duration, short- and long-term survivals, and late interventions.
  
  
  RESULTS
  Anatomic subtypes were single left ventricle (n = 88, 38.9%), single right ventricle (n = 78, 34.5%), common ventricle (n = 19, 8.4%), and heterotaxy syndrome (n = 41, 18.1%). Lateral tunnel connection was created in 69 patients (30.5%); extracardiac connection was created in 157 (69.5%). Mean age and weight at surgery were 4.3 +/- 3.8 years and 17.2 +/- 9 kg, respectively. In 2002, 14 of 16 patients (87.5%) had fenestrated Fontan circulations, versus 2 of 32 (6.3%) in 2008. Mean hospital stay was 10.8 +/- 8.8 days. Survival to discharge or 30 days was 98.7%. There were 2 (0.9%) late deaths during mean follow-up of 2.0 +/- 1.7 years. Outcomes were equivalent between fenestrated and nonfenestrated procedures across anatomic subtypes.
  
  
  CONCLUSIONS
  Highly selective use of Fontan fenestration is achievable while maintaining excellent outcomes without increased surgical morbidity or mortality, irrespective of anatomic subtype. Risks of hypoxia, systemic embolism, and late instrumentation can be avoided in most cases.
authors.affiliation: Division of Congenital Heart Surgery, Baylor College of Medicine, Houston, Tex, USA. salazar@umc.edu
authors.forename: Jorge D
authors.initials: JD
authors.lastname: Salazar
authors.forename: Farhan
authors.initials: F
authors.lastname: Zafar
authors.forename: Kashif
authors.initials: K
authors.lastname: Siddiqui
authors.forename: Ryan D
authors.initials: RD
authors.lastname: Coleman
authors.forename: David L S
authors.initials: DL
authors.lastname: Morales
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Heinle
authors.forename: Joseph W
authors.initials: JW
authors.lastname: Rossano
authors.forename: Emad B
authors.initials: EB
authors.lastname: Mossad
authors.forename: Charles D
authors.initials: CD
authors.lastname: Fraser
mesh_terms: D016009:Chi-Square Distribution; D002648:Child; D002675:Child, Preschool; D003422:Critical Care; D004322:Drainage; D005260:Female; D018729:Fontan Procedure / Q000009:adverse effects / Q000401:mortality; D006330:Heart Defects, Congenital / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D017052:Hospital Mortality; D006801:Humans; D007223:Infant; D007902:Length of Stay; D016014:Linear Models; D016015:Logistic Models; D008297:Male; D010166:Palliative Care; D010359:Patient Readmission; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D013781:Texas; D013997:Time Factors; D016896:Treatment Outcome