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The Journal of Thoracic and Cardiovascular Surgery, Vol 90, 391-398, Copyright © 1985 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
RA Hopkins, BE Armstrong, GA Serwer, RJ Peterson and HN Oldham Jr
The original Fontan procedure included a classic superior vena cava-to-
right pulmonary artery (Glenn) shunt. Subsequent experience demonstrated
that this anastomosis was not essential and was an unnecessary commitment
of the larger right pulmonary circulation to the smaller blood volume of
the superior vena caval return. With application of the Fontan principle to
more complex cardiac malformations, there has been a reconsideration of
possible benefits of a cavopulmonary shunt in selected patients. A modified
shunt from the divided end of the superior vena cava to the side of the
undivided right pulmonary artery utilized in 21 patients is described. This
shunt is designed to allow bidirectional pulmonary arterial distribution of
both superior vena caval inflow and right atrial outflow after completion
of the Fontan procedure. Twelve patients had the bidirectional shunt
performed prior to a Fontan operation; five of these had a subsequent
atriopulmonary connection and seven await operation. Eight patients had
construction of this shunt at the time of their Fontan procedure. One
patient had a bidirectional shunt constructed following atriopulmonary
anastomosis to help relieve right atrial outflow obstruction. Two patients
with univentricular heart undergoing simultaneous Fontan procedure and a
bidirectional shunt died while in the hospital. The remaining 19 patients
have been followed up for 2 months to 9 years with one late sudden death at
9 years. There have been no bidirectional cavopulmonary shunt failures,
stenoses, kinks, or recognized pulmonary arteriovenous malformations.
Postoperatively, eight patients had assessment of pulmonary distribution of
shunt blood flow by angiography. Seven of these patients were also
evaluated by radionuclide angiography. Superior vena caval blood flow via
the bidirectional cavopulmonary shunt tended to be greater to the right
lung, but bilateral pulmonary flow was documented in all but one patient.
After Fontan operation, six of seven patients tested also demonstrated
bilateral distribution of atriopulmonary flow. We concluded from our
experience that this modified shunt provides excellent relief of cyanosis,
allows bidirectional pulmonary distribution of both superior vena caval
return and also the right atrial blood flow after atriopulmonary
connection, and may be done before, with, or after a Fontan procedure and
is compatible with all currently recommended modifications. Perioperative
hemodynamic adjustments to the Fontan procedure may be improved by reducing
atrial volume, and this may also be of potential benefit in the long-term
adaptation to Fontan physiology by minimizing atrial distention.
ARTICLES
Physiological rationale for a bidirectional cavopulmonary shunt. A versatile complement to the Fontan principle
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