European Journal of Cardio-Thoracic Surgery, Vol 12, 107-115, Copyright © 1997 by European Association for Cardio-thoracic Surgery
Management of the univentricular connection: are we improving?
AD Cochrane, CP Brizard, DJ Penny, S Johansson, JV Comas, T Malm and TR Karl
Cardiac Surgical Unit, Royal Children's Hospital, Melbourne, Australia.
OBJECTIVE: To assess the impact of the bidirectional cavopulmonary shunt,
total cavopulmonary connection, and baffle fenestration on outcome of the
Fontan operation in our unit. METHOD: We reviewed 123 bidirectional
cavopulmonary shunts and 264 Fontan operations performed from 1980 to 1995.
Analysis of pulmonary artery size (right and left main and lower lobe
branches) before and after bidirectional cavopulmonary shunt was performed.
Outcome of the Fontan operation was analysed in various time periods to
assess the effect of prior bidirectional cavopulmonary shunt, use of the
lateral tunnel, and fenestration. RESULTS: Operative risk for the
bidirectional cavopulmonary shunt was 4% (CI = 2-10%) with a survival of
89% (CI = 83- 95%) at 36 months. Probability of conversion to Fontan
operation at 36 months was 49% (CI = 38-61%). Pulmonary artery size (Nakata
and lower lobe indices) fell after bidirectional cavopulmonary shunt (P =
0.0006). Fontan risk dropped from 8.5% (1980-1987) to 1.8% (1988-1995) (P =
0.02), coinciding with the use of the bidirectional cavopulmonary shunt.
There was no further risk reduction after introduction of the lateral
tunnel and baffle fenestration, although these comparisons are limited by
relatively small numbers. Duration of hospital stay related to pleural
effusions was lowest for patients with a fenestrated lateral tunnel
operation (P < 0.05). CONCLUSION: The bidirectional cavopulmonary shunt
is a suboptimal stimulus for pulmonary artery enlargement, but may reduce
the risk of Fontan operation in selected children. Fenestrated lateral
tunnel operations have reduced the duration of postoperative pleural
effusions.
