Outcomes of the Non-fenestrated Fontan Procedure at High Altitude

Abstract

Background: Although high altitude has been considered a risk factor for the Fontan operation, and an indication for fenestration, there is a paucity of data to support its routine use. Fenestration, with its necessary right to left induced shunt, together with the lower partial pressure of oxygen found with progressive altitude, can significantly decrease hemoglobin oxygen saturation, and therefore, it would be desirable to avoid it. Objective: To analyze immediate and medium-term results of the non-fenestrated, extracardiac, Fontan procedure at high altitude. Methods: Retrospective analysis of data from consecutive patients who underwent non-fenestrated, extracardiac, Fontan procedure at two institutions located in Mexico City at 2,312 m (7,585 ft) and 2,691 m (8,828 ft) above sea level. High altitude was not considered a risk factor. Results: Thirty-nine patients were included, with a mean age of 6.7 years. Mean preoperative indexed pulmonary vascular resistance was 1.7 Wood units. Seventy-nine percent of the patients extubated in the operating room. There was one in-hospital death (2.56%) and one at follow-up. Median chest tube drainage time was 6.5 and 6 days for the right and left pleural spaces. Median oxygen saturation at discharge was 90%. At a median follow-up of six months, all survivors, except one, had good tolerance to daily life activities. Conclusions: The present study shows good short- and medium-term results for the non-fenestrated, extracardiac, Fontan operation at altitudes between 2,300 and 2,700 m and might favor this strategy over fenestration to improve postoperative oxygen saturation. Further studies to examine the long-term outcomes of this approach need to be considered.

Early Extubation in a Pediatric Cardiac Surgery Program Located at High Altitude

“…[26][27][28][29] Recently, we reported our outcomes of nonfenestrated Fontan procedure patients at high altitude. 30 In this study, pre-and postoperative mean pulmonary artery (PA) pressure (and therefore probably also PVR) in patients undergoing the Fontan procedure at altitudes of 2,312 m and 2,691 m above sea level was within the normal range, and nonfenestration had, in addition, the beneficial effect of avoiding a necessary right to left shunt that could potentially worsen the saturation at these high altitudes. Overall, immediate outcomes were similar to those of another study of nonfenestrated Fontan performed at low altitude.…”

Respiratory physiology at high altitude and considerations for pediatric patients

“…Although oxygen saturation lower than their normal counterparts was measured both at exercise and at rest, the tolerance for exercise during short‐term exposure was similar and none of the subjects in this study decompensated. Patients receiving nonfenestrated Fontan operations living at high altitude had preserved oxygen saturations, and a nonfenestrated Fontan may be preferable to a fenestrated one with regard to oxygen saturation 31 32 .…”

The Fontan Procedure at Altitude: Fenestrate or Not?

“…[1][2][3][4] In this issue of the World Journal for Pediatric and Congenital Heart Surgery, Palacios-Macedo et al report very respectable earlyand medium-term outcomes in a series of 39 non-fenestrated Fontan procedures performed at two bona fide high-altitude centers in Mexico City (2,312 and 2,691 m). 5 The management protocol in this study was impressive, with an emphasis on early extubation and aggressive early use of pulmonary vasodilators. In the United States, the practice of Fontan fenestration remains controversial and highly variable among centers.…”