title: Intra- or extracardiac Fontan operation? A simple strategy when to do what.
abstract: BACKGROUND
  The complete Fontan circulation is the definite palliation for many complex congenital cardiac lesions. After bi-directional Glenn anastomosis (BDG), two well-established techniques - intracardiac tunneling and extracardiac prosthesis - are available for completion, although the choice of technique is still a matter of debate.
  
  
  METHODS
  We retrospectively reviewed the surgical and clinical records of patients with single ventricle physiology, who underwent intracardiac (group I) or extracardiac (group II) Fontan palliation after BDG.
  
  
  RESULTS
  Complete data were available in 72 patients. Thirty-eight patients received intracardiac (median weight: 12.6 kg) and 34 patients extracardiac repair (median weight: 15.6 kg). Patients with intracardiac tunneling had longer cardiopulmonary bypass (CBP) time (170 min vs. 104 min; p < 0.001), longer ventilatory (39 h vs. 21 h; p = 0.009) and longer inotropic support (48 h vs. 10 h; p < 0.001). Ventilatory and inotropic support were dependent on CPB (r = 0.69 and r = 0.637) and on aortic cross-clamping (r = 0.785 and r = 0.705 only group I), but not dependent on age, weight or pulmonary artery pressure (PAP).
  
  
  CONCLUSIONS
  Both techniques are feasible without perioperative mortality. Normally developed children with good hemodynamics after BDG received an elective extracardiac procedure without fenestration later. Patients with developmental retardation, severe progressive cyanosis, myocardial dysfunction, or moderate to severe atrio-ventricular valve insufficiency are scheduled for an earlier intracardiac baffle repair with routine fenestration, as they are at higher risk. Prolonged CPB and aortic cross-clamping times adversely impact the early postoperative course. Further strategies must be developed to avoid these effects, particularly in the patient group at higher imminent risk.
authors.affiliation: Department of Pediatric Cardiology, University Hospital, Mainz, Germany.
authors.forename: Wlodzimierz
authors.initials: W
authors.lastname: Kuroczynski
authors.affiliation: Department of Pediatric Cardiology, University Hospital, Mainz, Germany.
authors.forename: David
authors.initials: D
authors.lastname: Senft
authors.affiliation: Department of Biostatistics, University Hospital, Mainz, Germany.
authors.forename: Amelie
authors.initials: A
authors.lastname: Elsaesser
authors.affiliation: Department of Pediatric Cardiology, University Hospital, Mainz, Germany.
authors.forename: Christoph
authors.initials: C
authors.lastname: Kampmann
keywords: Fontan; univentricular heart