Total Cavopulmonary Connection: Lateral Tunnel Anastomosis or Extracardiac Conduit? — an Analysis of 114 Consecutive Patients

Chin Med Sci J June 2009

Vol. 24, No. 2 P. 76-80

CHINESE MEDICAL SCIENCES JOURNAL ORIGINAL ARTICLE

Total Cavopulmonary Connection: Lateral Tunnel Anastomosis or Extracardiac Conduit? –– an Analysis of 114 Consecutive Patients Song Fu1, Klaus Valeske2, Matia Muller2, Dietmer Schranz2*, and Hakan Akinturk2 1

Children’s Heart Center, Bayi Children’s Hospital, the Military General Hospital of Beijing People’s Liberation Army, Beijing 100026, China 2 Children’s Heart Center, University Hospital Giessen and Marburg GmbH, Giessen 35385, Germany

Key word: univentricular heart; total cavopulmonary connection; extracardiac conduit; lateral tunnel anastomosis Objective To compare the postoperative outcomes of patients with the diagnostic univentricular heart undergoing lateral tunnel (LT) operation with extracardiac conduit (EC) operation. Methods From June 1996 to July 2007, 114 consecutive patients with a single ventricle underwent total cavopulmonary connection (TCPC) in Children’s Heart Center, University Hospital Giessen and Marburg GmbH, Germany. A LT was performed in 19 (16.7%) patients, and an EC in 95 (83.3%) patients. The mean age of EC group was 50.8±31.6 (ranging from 22 to 212) months, and that of LT group was 61.5±41.2 (ranging from 30 to 168) months. Early and midterm outcomes of two groups were analyzed. Results One died in LT group (5.3%) and three in EC group (3.2%). The overall mortality was 3.5%. There was no significant difference in mortality between EC and LT groups (P>0.05). The postoperative pulmonary arterial pressure, oxygen saturation, and effusion time of two groups had no significant difference (all P>0.05). No significant difference in the occurrences of complications (arrhythmias, enteropathy, and thrombosis) was found between two groups after operation (P>0.05). Conclusions There seems no difference between LT and EC in the clinical results in the early and middle postoperative stage. Glenn anastomosis followed by an EC seems to have some advantages.

T

OTAL cavopulmonary connection (TCPC) includes

tricular heart underwent TCPC in Children’s Heart Center,

lateral tunnel anastomosis (LT) and extracardiac

University Hospital Giessen and Marburg GmbH, Germany.

conduit (EC). In the past ten years, 114 con-

The purpose of this report was to compare the outcomes of

secutive patients with the diagnostic univen-

univentricular heart patients receiving lateral tunnel anastomosis (LT) operation with those of receiving extracardiac conduit (EC) operation at a single institution

Received for publication June 16, 2008. *Corresponding author Tel: 49-641-99-43461, E-mail: Dietmar. [email protected]

over the same duration.

Vol. 24, No.2

CHINESE MEDICAL SCIENCES JOURNAL

PATIENTS AND METHODS

77

pacemaker-dependent rhythm or other rhythm according to a 12-lead electrocardiogram (Table 3).

Patients From June 1996 to July 2007, 114 consecutive patients

Operative technique

with the diagnostic univentricular heart underwent TCPC in

During intracardiac surgical procedures, antegrade crys-

Children’s Heart Center, University Hospital Giessen and

talloid cardioplegia solution (30 ml/kg, Bretschneider) was

Marburg GmbH, Germany. A LT was performed in 19

applied. For the lateral technique, a 0.4-mm thickness

(16.7%) patients, and 95 (83.3%) patients were treated

PTFE cardiovascular patch was used to create an access

with an EC using PTFE conduits. The cardiac morphology of

between inferior and superior vena cava to avoid injury to

patients is shown in Table 1. Most patients had been op-

either the pulmonary veins or the sinoatrial node. The

erated before (Table 2). Mean number of previous opera-

patch was always fenestrated with a 4-mm punch. The

tions in LT group and EC group was 2.1 and 1.9 respec-

divided superior vena cava was anastomosed to pulmonary

tively (P>0.05).

artery in an end-to-side fashion.

All patients underwent preoperative invasive assess-

The size of the PTFE conduit used in EC technique for

ment. Pulmonary arterial pressure (PAP) and oxygen

82 patients was 19 or 20 mm, 15 to 17 mm for 13 patients.

saturation (SaO2) were measured during cardiac cathe-

Transoesophageal echocardiography was routinely per-

terization. Atrioventricular valvar regurgitation was as-

formed.

sessed by echocardiography. Valve regurgitation was classified as one, two and three degrees, and equal or

Definition of postoperative outcomes

more than two degrees as “significant”. The features of

Early mortality was defined as death during the initial

the regurgitant flow were identified by pulsed wave

hospitalization or within the first 30 days after operation.

Doppler and color Doppler in the parasternal short-axis

Late mortality was defined as death after discharge of the

view and apical view. The patients were also divided into

hospital.

those with sinus rhythm, atrioventricular block, arrhythmia,

Table 1. Cardiac morphology of patients undergoing univentricular repair Group

n

LT group 19

AV-

HLHS

channel

2(10.5%)

EC group 95 26(27.3%)

*

DORV

PA with

DILV

TAT

VSD

1(5.9%)

2(10.5%) 3(15.7%)

3(15.7%)

7(7.4%)

*

*

6(6.3%)

9(9.4%)

7(7.4%)

All above

PA with

HRV

IVS

5(26.3%) 2(10.5%)

With a LV

With TGA

With a RV

1(5.9%) 11(57.8%) 8(42.1%)

26(27.3%) 7(7.4%)

8(42.1%)

7(7.4%) 59(62.1%) 36(37.8%) 29(30.5%)

LT: lateral tunnel; EC: extracardiac conduit; HLHS: hypoplastic left heart syndrome; AV: atrioventricular; DORV: double-outlet right ventricle; DILV: double inlet left ventricle; PA: pulmonary atresia; VSD: ventricular septal defect; TAT: tricuspid atresia; HRV: hypoplastic right ventricle; IVS: intact ventricular septum; With a LV: with a dominant left ventricle; With a RV: with a dominant right ventricle; TGA: transposition of the great arteries * P<0.05, compared with LT group

Table 2. Procedure before total cavopulmonary connection Group

n

Shunt

Banding

Glenn

PDA stent

LT group

19

11(57.8%)

4(21.0%)

11(57.8%)

2(10.5%)

EC group

95

94(98.9%)*

11(11.6%)

35(36.8%)*

15(15.8%)

Giessen-procedure

Norwood-procedure

0

2(10.5%)

13(13.7%)

24(25.3%)

*

P<0.05, compared with LT group

Table 3. Preoperative conditions of patients in two groups ( x Group

n Age(mon) Height(cm)

± s)

Valve regurgitation*

Weight(kg) PAP(mm Hg) SaO2(%)

MV

TV

Rhythm

AV

Sinus

Arrhythmia

LT group 19 61.5±41.2

116±29.2

25.4±17.4

10.2±2.2

82.2±6.0

0

0

1(5.2%)

16(84.2%)

3(15.7%)

EC group 95 50.8±31.6

101±18

16.4± 8

10.3±2.4

82.9±5.5

1(1.0%)

3(3.1%) 3(3.1%)

76(80.0%)

15(15.7%)

PAP: pulmonary arterial pressure; SaO2: oxygen saturation; MV: mitral valve regurgitation; TV: tricuspid valve regurgitation; AV: aortic valve regurgitation *

Systemic atrioventricular valve regurgitation and aortic valve regurgitation equal or more than two degrees are considered as significant

78

CHINESE MEDICAL SCIENCES JOURNAL

June 2009 RESULTS

We preoperatively measured PAP and SaO2 to see if there was a correlation of PAP and SaO2 with operative outcomes. Any pleural effusion that lasted for more than 10 days after operation came under the category of “significance”. If there was any recurrence of effusion after the removal of chest tubes, it was also included in the list of significant pleural effusions. The effusion rate and effusion time of two groups were analyzed. Any new onset of atrial flutter or fibrillation or need for pacemaker implantation was defined as arrhythmia. The occurrence of arrhythmia in LT and EC groups was assayed. Echocardiographic studies were performed as routine follow-up protocol either in our clinic or by referring cardiologists. Other complications, such as thrombosis in the conduit, gastroenteric and neural complications, were observed postoperatively.

A total of 114 patients were operated with LT or EC Fontan procedure. The overall mortality was 3.5% (4/114). The mortalities of LT group and EC group were 5.3% (1/19) and 3.2% (3/95), respectively. There was no significant difference in mortality between two groups (P>0.05) (Table 4). The postoperative PAP and SaO2 significantly increased compared with the preoperative ones in both groups (P<0.001). But there was no significant difference in postoperative PAP or SaO2 between two groups (P>0.05) (Table 4). Every patient postoperatively suffered from effusion. Both effusion rate and effusion time of two groups had no significant difference (P>0.05). In LT group, 5 patients suffered from arrhythmia after operation, and 19 patients in EC group. There was not significant difference (P>0.05) (Table 4). A total of 11 patients showed a thrombosis in the

Statistical analysis The SPSS software version 10.0.0 for Windows (SPSS Inc., Chicago, IL, USA) was used for data analysis. Initially, all numerical data were tested for normality using the Kolmogorov-Smirnov test. The unpaired Student´s t-test and Mann-Whitney test were used to compare the difference of numeric data between two groups. For categorical data, the Fisher´s exact test was used. Numerical data were shown as x ± s . Statistical significance was defined as P

conduit postoperatively, and all of them belonged to EC group. But the difference between the two groups was not of significance (P>0.05) (Table 4). An enteropathy appeared in 2 patient receiving LT and 1 receiving EC. Neural complications appeared in 8 patients. Three of them belonged to the LT group and five to the EC group. Besides of two, other patients only suffered the transient symptoms.

value less than 0.05. Table 4. Outcomes of univentricular heart patients undergoing LT operation and EC operation ( x Early mortality

Late mortality

PAP

SaO2

Occurrence of

Thrombosis

(%)

(%)

(mm Hg)

(%)

(d)

(%)

arrhythmia (%)

rate (%)

19

5.3

0

14.0±6.6

90.4±5.3

12.8±12.0

31.5

26.3

0

95

2.1

1.1

13.2±4.1

90.9±4.6

10.0± 9.2

32.6

20.0

Group

n

LT group EC group

Effusion time Effusion rate

± s)

11.5

The second step, the so-called TCPC consists either of a

DISCUSSION

LT or an EC. We performed LT operation on a group of 19 patients totally and found no difference in mortality and

Numerous technical modifications of the Fontan op-

hemodynamics examining between LT and EC Fontan pa-

eration have been introduced, many of which have had an

tients, and it was the same as Gaynor and co-workers’

impact on the outcome of the operation. The mortality rate

results.2

of the Fontan operation has been reduced by dividing the

LT operation directs inferior vena cava blood in a

procedure into two stages. The hemi-Fontan or bidirec-

laminar fashion along the lateral free wall of right atrium to

tional Glenn procedure is performed as the first step and

right pulmonary artery. A patch is placed from the inferior

allows early reduction of the work volume of the single

vena cava to the superior vena cava, which is divided and

ventricle and a gradual remodeling of ventricular geometry

each end sewn end-to-side to the right pulmonary artery,

before completion of the Fontan operation. Using this ap-

thereby excluding a large part of the right atrium from the

proach, the mortality has decreased from 16% for a pri-

tunnel. Growth potential of the tunnel is maintained by

mary Fontan operation to 8%.

1

including a portion of the lateral or back wall of the right

Vol. 24, No.2

CHINESE MEDICAL SCIENCES JOURNAL

79

atrium along one side.1 Besides a maybe generally deci-

to have some advantages, especially in the onset of ar-

sion for this technique, the LT is the favored technique

rhythmias.9 Azakie and co-workers9 also found a lower

usually in very young patients or in cases of different

level of atrial natriuretic peptide in patients with EC tech-

anatomy as dextrocardia. This is also reported by other

nique compared to LT patients demonstrating less pressure

groups, like from Kumar and co-workers.3 However, al-

load in the atrium.

though the postoperative PAP of LT was no significant

Routine fenestration is controversially discussed.12-14

statistical difference with that of EC, the damage would be

In our study, intraoperative fenestration was applied in 68

made to the cardiac muscle because of aortic cross-

of 114 (LT group: 10, 52.6%; EC group: 58, 61%), who

clamping, which perhaps would be the reason of heart

have been classified as higher risk patients, according to

failure postoperatively. As mentioned before, in cases of

the recommendation of other groups.15 And 46 of 114 (LT

intracardiac procedures antegrade crystalloid cardioplegia

group: 9, 47.3%; EC group: 37, 38.9%) was not fenes-

(Bretschneider) was once 2.5-3 hours applied. It is better

trated because they seemed to be in such a good preop-

than Thomas’ that was once applied in 20 minutes. And

erative status, that a routine fenestration appeared un-

another, in the procedure, whether LT or EC, a special kind

necessary. Due to that inconspicuous preoperative data, a

of bicaval cannulation (8-10F, 330 mm, PUN0026-0028,

secondary fenestration was needed in 35% of the un-

Stockert Company, Munich, Germany) was used. It could

fenestrated patients, because of a clinically failing Fontan

provide with more space for the operating by reason of the

circulation. Our fenestrated patients showed significant

diameter being much smaller in the same flux than that of

lower PAPs (which is always a predictor of hemodynamic

other bicaval cannulation.

situation in Fontan circulation) than the non-fenestrated

The extracardiac approach for completion of the Fontan

and none of the fenestrated patients showed signs of a

procedure, in which a PTFE-prosthesis is placed between

failing Fontan in the immediate postoperative time.

the inferior vena cava and the pulmonary artery, has many

Bowman and co-workers16 found that absence of a fenes-

potential advantages, simplifying the procedure of com-

tration was the only significant predicting factor of Fontan

pletion by avoidance of aortic cross-clamping and giving a

failure.

shorter duration of cardiopulmonary bypass.4,

5

Further-

In conclusion, there seems no difference between LT

more, it possibly provides a more streamlined hydrody-

and EC in the clinical result on early and middle postop-

namic connection6-8 and is associated with a decreased

erative stage; and the combination of a previous Glenn

frequency of arrhythmia at midterm.

4, 9

The procedure is

widely recognized as the approach with the greatest potential for optimizing postoperative results.5,

9-11

anastomosis followed by an EC seems to have some advantages.

Hemo-

dynamically, it offers the most efficient design for pre-

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