Clinical Results of the Staged Fontan Procedure in High-Risk Patients

Single stage versus two stage repair for univentricular heart—our experience

“…Lee and colleague in their study have found a lower actuarial mortality (16.3 vs. 41.3%, p, 0:001) for the Fontan operation in the group in which the Fontan procedure was finished via Bidirectional Cavopulmonary Shunt (BCPS) than in the group finished without BCPS [11]. Masuda et al [7] reported a lower mortality and the higher probability to complete the Fontan procedure when using a preliminary [12] in their study of 75 patients have found higher mortality of 14.2% vs. 7.4% in the group of two stage TCPC than in the primary TCPC group. The mortality differed in three preoperative risk groups: in low risk group 4% vs. 0%, in moderate risk group 6% vs. 0%, and in high risk group 15% vs. 75% in primary correction group and two stage group, respectively.…”

“…Particularly, BDG as initial palliative procedure towards staging the TCPC has been considered for those patients at high risk for primary TCPC because of low age, significant pulmonary artery hypoplasia, elevated mean pulmonary artery pressure and pulmonary resistance, significant ventricular hypertrophy and impaired ventricular function. Many previous studies have shown excellent results in high-risk Fontan candidates who have undergone BDG before TCPC and in many cases BDG preceding TCPC may extend the indications for the Fontan procedure [4][5][6][7].…”

“…One of the major improvements of the last decade or so resulting in a significant decrease in morbidity and mortality following modified Fontan/TCPC procedures has been the concept of staging by a preceding Bidirectional Glenn procedure (BDG). High-risk Fontan candidates who have undergone BDG before TCPC have shown excellent results and in many cases BDG preceding TCPC may extend the indications for the Fontan procedure [4][5][6][7]. The exact mechanism for the superiority of BDG, though, still poorly understood may be the fact that volume reduction of BDG preceding TCPC allows for any afterload mismatch to be corrected, thereby improving ventricular energetics after TCPC [8].…”

Transition of ventricular function and energy efficiency after a primary or staged Fontan procedure

“…25 In the staged group, from the viewpoint of the afterload mismatch, it is compatible with the hypothesis suggesting that the impact of the impaired diastolic ventricular compliance is alleviated because only the superior venous blood has to fl ow through the pulmonary vasculature. 4 The impaired diastolic ventricular fi lling caused by the inappropriate ventricular hypertrophy and addition of the total pulmonary vascular resistance to the systemic vascular resistance synergistically might have caused a reduced EF during the early phase after TCPC in the primary group.…”

“…1,2 However, abrupt removal of ventricular volume load after single-stage total cavopulmonary connection causes postoperative changes in ventricular geometry and may have an important impact on cardiac function. 3,4 This is one of the reasons that a staged total cavopulmonary connection strategy has been widely accepted for high-risk patients. 5,6 So far, pre-and postoperative hemodynamic indices have been evaluated in many institutions, but comparative review of these indices at different time points after primary and staged total cavopulmonary connection has not been done.…”