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Eur J Cardiothorac Surg 2008;34:550-555. doi:10.1016/j.ejcts.2008.04.043
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
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Right arrow Congenital - cyanotic

Bidirectional cavopulmonary connection without additional pulmonary blood flow as an ideal staging for functional univentricular hearts

Christian Schreibera,1,*, Julie Cleuzioua,1, Juliane K. Cornelsena, Jürgen Hörera, Andreas Eickenb, Rüdiger Langea

a Department of Cardiovascular Surgery, German Heart Center Munich at the Technical University Munich, Germany
b Department of Paediatric Cardiology and Congenital Heart Disease, German Heart Center Munich at the Technical University Munich, Germany

Received 7 November 2007; received in revised form 28 March 2008; accepted 29 April 2008.

* Corresponding author. Address: Clinic of Cardiovascular Surgery, German Heart Center Munich at the Technical University Munich, Lazarettstrasse 36, 80636 Munich, Germany. Tel.: +49 89 12184111; fax: +49 89 12184113. (Email: schreiber{at}dhm.mhn.de).


   Abstract
Top
 Abstract
1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 Appendix A
 References
 
Objective: Our institutional policy differs from others substantially, as we never leave any additional blood flow at the time of performing bidirectional cavopulmonary connection (BCPC). The aim was to evaluate the influence of this strategy on hemodynamics and pulmonary artery development. Methods: Between 2001 and 2006 a total of 124 patients had completion to a total cavopulmonary connection (TCPC). Review of 84 angiograms before BCPC and TCPC allowed for analysis of hemodynamic findings and measurement of the pulmonary arteries (PA). Results: Mean age at BCPC was 12.6 ± 15.3 months. Mean age at time of TCPC was 31.3 ± 18.7 months, with an interval of 18.6 ± 11.8 months between BCPC and completion to extracardiac TCPC. There was no postoperative mortality after BCPC, one patient died after TCPC (1.2%). The mean oxygen saturation increased after BCPC from 74.4% to 79.6% (p < 0.01). The mean PA pressures decreased after BCPC from 15.1 to 13.5 mmHg (n.s.). The mean left atrial pressure decreased from 5.8 to 4.9 mmHg prior to TCPC (p = 0.06). The pulmonary/systemic blood flow ratio was 1.4 prior to BCPC and decreased to 0.67 prior to TCPC (p = 0.04). The pulmonary/systemic resistance ratio decreased also from 0.19 to 0.07 prior to TCPC (p < 0.01). The right PA, as well as the right lower lobe PA, showed a significant increase in diameter after BCPC (p < 0.01). The left PA also increased in size, although this was not statistically significant. Conclusions: After BCPC without additional blood flow, hemodynamic findings are favorable for completion of TCPC. Our findings support our institutional policy not only for an early staging to a BCPC, but likewise a swift completion towards a TCPC.

Key Words: Congenital heart disease • Partial cavopulmonary connection • Bidirectional cavopulmonary connection • Total cavopulmonary connection


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patients and methods
 3. Results
 4. Discussion
 Appendix A
 References
 
Whether or not additional pulmonary artery blood flow (APBF) at the time of bidirectional cavopulmonary connection (BCPC) influences the final outcome after completion to a total cavopulmonary connection (TCPC) remains to date unclear. Many reports hint at APBF being helpful for pulmonary artery growth and, obviously, systemic oxygenation [1,2]. Mainwaring and co-workers [3] investigated 149 patients in whom 93 had elimination of all sources of APBF. The results after completion to TCPC demonstrated a significant survival advantage when APBF was eliminated at time of BCPC. They postulated that this survival advantage may have been based on improvement in pulmonary resistance and ventricular function. An ABPF therefore influences ventricular volume and unloading, and central venous pressure together with pulmonary artery pressure and resistance.

Our described results reflect a potentially changing overall treatment pattern. Patients’ staging can be accomplished earlier in life, with a BCPC alone proving to be perfectly sufficient until conversion to a TCPC within the first 2–4 years of life. Therefore, a meaningful comparison of previously published reports must take the patients’ age at each stage and institutional characteristics into account. This manuscript focuses on the assessment of pulmonary artery diameters from BCPC up to TCPC and immediate clinical results after TCPC.


   2. Patients and methods
Top
 Abstract
 1. Introduction
 2. Patients and methods
3. Results
 4. Discussion
 Appendix A
 References
 
Between 2001 and 2006 a total of 124 patients had completion of an extracardiac TCPC. Where adequate angiographic imaging were provided, hemodynamic findings and measurements of the pulmonary artery tree were analyzed before BCPC and before TCPC, respectively. One investigator obtained all angiographic measurements. Each pulmonary artery was measured proximal to the first branching point. In addition, the right and the left lower lobe artery were investigated. Measurements were performed at systole yielding the maximum size of the pulmonary arteries and compared to normal values as investigated by Daubeney and co-workers [4]. Graduation of collaterals was estimated approximately (wash-out from the pulmonary arteries during catheterization).

The origin of pulmonary artery blood flow prior to BCPC varied and is summarized in Table 1 . This study has been approved by the ethics committee of the Technical University Munich (1740/07). The ethics committee waived the need for individual patient consent for this study.


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  		Table 1 Characteristics of 84 patients
 
2.1 Statistical analysis
Descriptive statistics are described as frequencies and percentages for categorical variables and as medians with range or means with standard deviation for continuous variables. Fischer's exact test or McNemar's test was performed to detect significant differences between groups (two-tailed tests were used for all analyses). Statistical significance was defined as p < 0.05. Statistical analysis was done using SPSS statistical software (Version 15.0.1, SPSS Inc., Chicago, IL).


   3. Results
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
4. Discussion
 Appendix A
 References
 
Patient characteristics are summarized in Table 1. Mean age at BCPC was 12.6 ± 15.3 months. Mean age at time of TCPC was 31.3 ± 18.7 months, with an interval of 18.6 ± 11.8 months between BCPC and completion to extracardiac TCPC. Pulmonary artery pressures at time of BCPC and just before completion to TCPC are depicted in Fig. 1 .


Figure 1
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  		Fig. 1. Diameter of the right pulmonary artery (RPA) prior to bidirectional cavopulmonary connection (BCPC) and prior to total cavopulmonary connection (TCPC). Upper and lower boxplot margins represent the interquartile range; middle bar indicates the median; vertical lines represents data within the 1.5 fold interquartile range above the third and below the first quartile; data which lie 1.5 interquartile range higher than the third quartile are considered as outliers and depicted as circles.

 
Mean cardiopulmonary bypass time was 86.8 ± 39.3 min (range 31–212 min).

Pulmonary artery sizes at time of BCPC and just before completion to TCPC are summarized in Figs. 1–3. Fig. 1 depicts the mean increase of the right pulmonary artery between the stages, Fig. 2 the increase of the left pulmonary artery, and Fig. 3 focuses on diameter differences in unilateral and bilateral BCPC. The z-scores for the right pulmonary artery were –0.25 ± 1.7, and –1.01 ± 1.5 for the left pulmonary artery.


Figure 2
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  		Fig. 2. Diameter of the left pulmonary artery (LPA) prior to bidirectional cavopulmonary connection (BCPC) and prior to total cavopulmonary connection (TCPC). Upper and lower boxplot margins represent the interquartile range; middle bar indicates the median; vertical lines represents data within the 1.5 fold interquartile range above the third and below the first quartile; data which lie 1.5 interquartile range higher than the third quartile are considered as outliers and depicted as circles.

 

Figure 3
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  		Fig. 3. Diameter of the left pulmonary artery (LPA) and the left lower lobe pulmonary artery (LLLPA) prior to unilateral and bilateral bidirectional cavopulmonary connection (BCPC). Dots indicate mean values; vertical lines represent 95% confidence limits.

 
Prior to BCPC we found collaterals in 14 patients. Seven patients had mild collaterals, five had moderate and two severe collaterals. By the time of the second angiogram prior to TCPC, the amount of patients with collaterals had increased to 59 (p < 0.001). There were 12 patients with severe collaterals, 29 with moderate and 18 with mild collaterals. Only in four patients was a coil occlusion of collaterals performed.

There was no postoperative mortality after BCPC, one patient died after TCPC (1.2%). Mean oxygen saturation increased after BCPC from 74.4% to 79.6% (p < 0.01). Mean pulmonary artery pressures decreased after BCPC from 15.1 to 13.5 mmHg (n.s.). The mean left atrial pressure decreased from 5.8 to 4.9 mmHg prior to TCPC (p = 0.06). The pulmonary/systemic blood flow ratio was 1.4 prior to BCPC and decreased to 0.67 prior to TCPC (p = 0.04). The pulmonary/systemic resistance ratio decreased also from 0.19 to 0.07 prior to TCPC (p < 0.01).

Median duration of pleural effusions was 4 days. In all patients a Gore-Tex® tube of at least 18 mm was inserted at the time of TCPC. Incision of the lower surface of the pulmonary artery, right up to the bifurcation, allowed enlargement of the pulmonary arterial pathway. In only six patients an additional pulmonary artery patch plasty was necessary.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
Appendix A
 References
 
Our data suggest that a BCPC alone allows for favorable results in completing a TCPC.

It is of note, however, that our institutional policy foresees not only an early staging towards a BCPC, but likewise a swift completion within the first 2–4 years of life. Pulmonary artery size is not of utmost importance when it comes to completing a TCPC in the now preferred fashion of an extracardiac modification. There are consistent findings from studies investigating pulmonary arteries and proof that pulmonary artery growth does not match the increase in body size after staging to a Fontan-like circulation [5–7]. Our findings suggest that the pulmonary arteries grew between the staging phases, however, not proportionally to body surface area with z-scores for the right pulmonary artery of –0.25 ± 1.7 and –1.01 ± 1.5 for the left pulmonary artery. Interestingly, even with APBF, pulmonary arteries do not show a normal growth. This has been clearly shown in the collective of Berdat and co-workers [1] and Yoshida and co-workers [2]. Berdat, who compared patients with a BCPC alone with those who had an APBF, found that left and right pulmonary artery dimensions were smaller than normal in all groups. APBF did show slightly increased pulmonary artery diameters but failed to reach significance compared to BCPC alone. Yoshida suggested an appropriate APBF together with a BCPC. As a guidance to appropriate APBF they monitored central venous pressures intraoperatively. However, even with this measure, pulmonary artery growth retardation could only be suppressed slightly. But again, they have not demonstrated that APBF made any difference in clinical outcome.

Although timing of staging procedures, pulmonary artery pressures and blood flow contribute to pulmonary artery distension and are likely affecting growth, other surgical aspects must also be taken into consideration. Reddy and co-workers [8] were the first to look at parts of the pulmonary artery tree which are generally not involved in any surgical augmentation procedures. In investigating the lower lobe pulmonary artery branches as well as the central areas, they elaborated that measurements of central pulmonary arteries alone, as done in previous publications, may have been a dubious approach in analyzing pulmonary artery growth in the context of a BCPC. In our study, a patch enlargement of the pulmonary artery was performed in 36 patients (42.8%) at time of BCPC.

It is of note, that 13.1% had a bilateral PCPC. As depicted in Fig. 3 the diameters for the lower lobe left pulmonary artery varied for both unilateral and bilateral PCPC. Even though an increase in diameter for the lower lobe pulmonary artery together with a bilateral BCPC was found it failed statistical significance. Still, the findings suggest a benefit of an even blood flow distribution.

Since we never leave any APBF there is also generally no need for extensive dissection and search for the sometimes-difficult access to the pulmonary trunk or any shunt at the time of TCPC.

Other institutions even claim underdeveloped pulmonary arteries as a reason not to complete staging treatment towards a TCPC [2]. Likewise, Tanoue and co-workers [9] reported on 333 patients with BCPC and an APBF in 163. Median age was 15 months. A TCPC was performed after a mean of 23 months, however, 66 patients are still awaiting completion. In our experience on now more than 150 patients after a TCPC since 1999, and the introduction of the extracardiac approach [10], we usually go ahead with completion once the patient weighs 10 kg, regardless of any other cardiac features. To us, the patients’ age at each staging procedure seems to be the key to potential procedure related mortality and morbidity. As we have shown in a cohort of 132 consecutive patients after unfenestrated TCPC [11] in a multivariate analysis early BCPC a short interval from BCPC to TCPC influenced the overall results positively. Of these patients, the majority was relatively young at the time of TCPC, with a median age of 31 months. A BCPC without APBF was accomplished in 91%. The median duration of hospitalization among the 30 days survivors was 20 days (range 5–128 days). Among 6 variables with values of p below 0.10 in single covariate models, the multiple covariate model revealed only older age at the time of extracardiac TCPC (p = 0.040) as a risk factor for prolonged hospitalization.

To add to this discussion of pulmonary artery size and its possible impact on outcome, Hosein and co-workers [12] published a recent study on whether conventional selection criteria were still applicable in the current era. Their analysis identified that outcome was influenced by preoperatively impaired ventricular function, elevated preoperative pulmonary artery pressures and an earlier year of operation. Risk factors for reintervention were right atrial isomerism and preoperative small pulmonary artery size. It is of note, that not only is their follow-up longer than in our study, but also that pulmonary artery size alone is not necessarily predictive in both early- and mid-term outcome. We assessed not only pulmonary artery sizes but also pulmonary/systemic blood flow ratio and pulmonary/systemic resistance ratio. Mean pulmonary artery pressures were low. We believe that this is probably the more important issue. Likewise, Hosein and co-workers comment was ‘... that only two criteria have emerged as carrying significant impact on both early and late outcome: preoperative ventricular function and preoperative pulmonary artery pressure.’ Most authors would suggest that the mean pulmonary artery pressure before TCPC should be less than 18 mmHg, or ideally less than 15 mmHg, with a calculated pulmonary vascular resistance less than 2.0 units/m2 [13,14]. Regarding the diameter of the pulmonary arteries the measurements do not take into consideration the compliance of the vascular bed.

Data of Forbes and co-workers [15] indicated that a BCPC facilitated ventricular volume unloading and regression of ventricular mass in younger children (<3 years of age), and that the beneficial effect of this operation on ventricular end-diastolic volume and mass was clearly age-dependent. Their data also showed that older patients benefited less in terms of enhancing the systemic oxygen saturation from the BCPC. Also Mainwaring and co-workers’ [3] findings support our preferred strategy. They investigated 149 patients. Ninety-three of these had elimination of all sources of APBF. The results after completion to TCPC demonstrated a significant survival advantage when APBF is eliminated at time of BCPC. They postulated that this survival advantage may be based on improvement in pulmonary resistance and ventricular function. Other long-term follow-up studies demonstrate significant late morbidity and mortality following Fontan-type of surgery related (among others) to ventricular dysfunction [16,17]. Indeed, reduced systolic ventricular function has been assessed in this group of patients [18]. A BCPC has been shown to significantly reduce ventricular end-diastolic volume [19,20]. Applying different echocardiographic techniques (Doppler myocardial echocardiography and M-mode echocardiography), systolic ventricular function can be assessed as demonstrated in a group of patients with tricuspid atresia after staged univentricular palliation [21]. Performing a Fontan operation at a later state is known to result in increased ventricular diameters at short and mid-term follow-up [22].

Diffuse intrapulmonary shunts are reported shortly after a BCPC. This may be due to a lack of liver factors as blood from the liver bypasses the lung in this condition, if no accessory pulmonary blood flow is present [23,24]. However, we could show that the only effective treatment for this condition is a cavopulmonary completion [25]. Early completion to a total cavopulmonary connection may prevent recurrent severe cyanosis, a well known late complication after a classical Glenn shunt operation [26]. Hence, we believe that there is absolutely no reason to volume load a functionally univentricular heart at the time of a BCPC with an additional shunt. Early completion to a total cavopulmonary connection leads to early volume unloading of the systemic ventricle and minimizes the risk to severe intrapulmonary right-to-left shunting. To date we do not know how pulmonary artery sizes develop after an extracardiac TCPC at long-term as most patients do well and do not require repeat catheterization. A prospective trial with, for example, repeated magnetic resonance imaging may allow for further insight into the issue of pulmonary artery growth together with our preferred timely completion to an extracardiac TCPC.


   Appendix A
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 Appendix A
References
 
Conference discussion

Mr V. Tsang (London, United Kingdom): The hemodynamics in your patient population, the PA pressure was 15, the LA pressure was 5 or 4, the Qp/Qs was 1.4, and you mentioned you don’t fenestrate and there are no effusions. Why don’t you do it in one stage and do it early?

Dr Schreiber: That's a good question. Maybe we’ll embark on that in the near future. Our recent paper on completion to TCPC is out just now. We report on 132 consecutive patients in whom we did not perform a fenestration. There are some patients who were in intensive care for 4 weeks, but eventually they all went home without a fenestration. Even with our extensive experience we still cannot predict precisely who will worsen after completion, or who will go home after one week. I think work is in progress. Professor de Leval was giving a very nice lecture on this topic yesterday, highlighting the controversies. Maybe there are a few surgeons here who will, with a good working BCPC and a nicely oxygenated child with good ventricular function, just wait 2, 3, 4, 5, 6 years and only then go for a TCPC. Our presented results represent retrospective findings, but we should just continue to exchange ideas in the future.

Dr J. Fragata (Lisbon, Portugal): We have not been doing exactly this. We have always been leaving an additional source of blood to the pulmonary arteries, aiming for the pulsatile flow and the growth for the arteries. But doing them earlier, completing the second stage earlier, by 2 years of age, and doing them extracardiac, as we are doing, what kind of artificial conduits do you use, or do you try to mobilize and do direct anastomosis? The size of the conduit, we don’t know exactly how big, but I am always reluctant to use less than a 16 or even an 18.

Dr Schreiber: We only use 18 mm tubes which fit nicely into a child weighing 10 kg.

Dr Fragata: Even at this age group?

Dr Schreiber: Yes.

Dr Fragata: So at 2 years of age?

Dr Schreiber: Yes. And maybe because we prefer simplicity we only dissect the right side of the heart out. Without any sources of additional blood flow not even the pulmonary trunk or a shunt have to be freed from adhesions. After dissection of the right side of the heart you can go on CPB for 30 to 40 min and simply complete the extracardiac pathway.

Dr B. Maruszewski (Warsaw, Poland): I want to confirm from our experience in the past that we were also leaving additional pulsatile blood flow, and we found in our series of patients that the PAs do not grow, and that if you look at the normalized PA size over time, it's actually decreasing. So we stopped doing this. What is your rationale for the final stage, for the TCPC; what is your decision-making if you do it in a 1-1/2-year-old patient or a 4-year-old patient? Is it the size of conduit? And do you believe that an 18 mm conduit in an extracardiac Fontan will last forever, will be enough for the adult life?

Dr Schreiber: For the last part of your question, there are quite a few publications out there that were investigating adults. It looks like an 18 mm diameter tube system will allow for older age. Because of that, you probably do not have to go back. If there will be some kind of distortion once the infant has grown-up, we do not know yet. And to the first part of your question, that is just our institutional policy. We try to avoid fistulae which might develop. We try to allow for hepatic blood to go into both lungs. Our data represent our institutional policy for the last 5 or 6 years. And finally, referring to the pulmonary sizes, the available publications give proof that even with an additional blood flow pulmonary arteries do not grow as they grow in healthy children.

Dr A. Amodeo (Rome, Italy): We can probably answer the question if the conduit, an 18 mm can last. We inserted the first extracardiac conduit in 1988, and in the first year we used a Dacron conduit. So the first group of patients, 35 patients, have a mean follow-up of almost 15 years, and in these patients we have never changed any conduit. So probably there is really no worry about the late fate of an extracardiac conduit. And, as I told you, the first conduit we had been using was a Dacron conduit. When you say that you use 18 mm conduits in any patient, well, sometimes I find it very difficult to put an 18 mm conduit in any kilogram patient, believe me, and I have to put a 16 Gore-Tex conduit, and even 14 sometimes in a smaller patient.

Mr V. Tsang (London, United Kingdom): Can I just push one point. You guys in Munich are crazy about early unloading and no antegrade flow.

Pascal, can you comment on mixed circulation?

Dr P. Vouhe (Paris, France): Well, I can comment, but I always say the same thing. I think it's a matter of philosophy. Either you think that the Fontan circulation is the best thing for the patient, and you should do it as early as possible, as you do, with excellent early and midterm results. On the contrary, you think that the Fontan circulation is the worst thing, as we do, because of all the potential complications which may occur. In this case the best for the patient is to delay Fontan completion as long as possible, and if you want to delay as long as possible, it is usually useful to leave some source of additional blood flow. We have shown in previous papers that it is not deleterious to leave some additional pulmonary blood flow.

Mr Tsang: It's nice to have a balanced view about things.

Dr C. Sebening (Heidelberg, Germany): I have a question relating to the complex that Pascal evoked. In the sole source of pulmonary blood supply by an exclusive bidirectional Glenn shunt, if you palliate them early, did you observe an increased incidence of pulmonary arteriovenous fistula, if this is the sole source of pulmonary blood supply?

Dr Schreiber: No.


   Footnotes
 
{star} Presented at the 21st Annual Meeting of the European Association of Cardio-thoracic Surgery, Geneva, Switzerland, September 16–19, 2007.

1 Both these authors contributed equally towards this paper. Back


   References
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 Appendix A
 References
 

  1. Berdat PA, Belli E, Lacour-Gayet F, Planche C, Serraf A. Additional pulmonary blood flow has no adverse effect on outcome after TCPC. Thorac Cardiovasc Surg 2004;52:280-286.[CrossRef][Medline]
  2. Yoshida M, Yamaguchi M, Yoshimura N, Murakami H, Matsuhisa H, Okita Y. Appropriate additional pulmonary blood flow at the bidirectional Glenn procedure is useful for completion of total cavopulmonary connection. Ann Thorac Surg 2005;80:976-981.[Abstract/Free Full Text]
  3. Mainwaring RD, Lamberti JJ, Uzark K, Spicer RL, Cocalis MW, Moore JW. Effect of accessory pulmonary blood flow on survival after the bidirectional Glenn procedure. Circulation 1999;100(19 Suppl.):II151-II156.[Medline]
  4. Daubeney PE, Blackstone EH, Weintraub RG, Slavik Z, Scanlon J, Webber SA. Relationship of the dimension of cardiac structures to body size: an echocardiographic study in normal infants and children. Cardiol Young 1999;9:402-410.[Medline]
  5. Mendelsohn AM, Bove EL, Lupinetti FM, Crowley DC, Lloyd TR, Beekman 3rd. RH. Central pulmonary artery growth patterns after the bidirectional Glenn procedure. J Thorac Cardiovasc Surg 1994;107:1284-1290.[Abstract/Free Full Text]
  6. Slavik Z, Webber SA, Lamb RK, Horvath P, LeBlanc JG, Keeton BR, Monro JL, Tax P, Tuma S, Reich O, Sandor GGS, Daubeney PEF, Salmon AP. Influence of bidirectional superior cavopulmonary anastomosis on pulmonary arterial growth. Am J Cardiol 1995;76:1085-1087.[CrossRef][Medline]
  7. Tatum GH, Sigfusson G, Ettedgui JA, Myers JL, Cyran SE, Weber HS, Webber SA. Pulmonary artery growth fails to match the increase in body surface area after the Fontan operation. Heart 2006;92:511-514.[Abstract/Free Full Text]
  8. Reddy VM, McElhinney DB, Moore P, Petrossian E, Hanley FL. Pulmonary artery growth after bidirectional cavopulmonary shunt: is there a cause for concern?. J Thorac Cardiovasc Surg 1996;112:1180-1190.[Abstract/Free Full Text]
  9. Tanoue Y, Kado H, Boku N, Tatewaki H, Nakano T, Fukae K, Masuda M, Tominaga R. Three hundred and thirty-three experiences with the bidirectional Glenn procedure in a single institute. Interact Cardiovasc Thorac Surg 2007;6:97-101.[Abstract/Free Full Text]
  10. Schreiber C, Kostolny M, Weipert J, Holper K, Vogt M, Hager A, Haas F, Hess J, Lange R. What was the impact of the introduction of extracardiac completion for a single center performing total cavopulmonary connections?. Cardiol Young 2004;14:140-147.[CrossRef][Medline]
  11. Schreiber C, Horer J, Vogt M, Cleuziou J, Prodan Z, Lange R. Nonfenestrated extracardiac total cavopulmonary connection in 132 consecutive patients. Ann Thorac Surg 2007;84:894-899.[Abstract/Free Full Text]
  12. Hosein RB, Clarke AJ, McGuirk SP, Griselli M, Stumper O, De Giovanni JV, Barron DJ, Brawn WJ. Factors influencing early and late outcome following the Fontan procedure in the current era. The ‘Two Commandments’?. Eur J Cardiothorac Surg 2007;31:344-352.[Abstract/Free Full Text]
  13. Freedom RM, Nykanen D, Benson LN. The physiology of the bidirectional cavopulmonary connection. Ann Thorac Surg 1998;66:664-667.[Abstract/Free Full Text]
  14. Chang AC, Hanley FL, Wernovsky G, Rosenfeld HM, Wessel DL, Jonas RA, Mayer Jr. JE, Lock JE, Castaneda AR. Early bidirectional cavopulmonary shunt in young infants. Postoperative course and early results. Circulation 1993;88:II149-II158.[Medline]
  15. Forbes TJ, Gajarski R, Johnson GL, Reul GJ, Ott DA, Drescher K, Fisher DJ. Influence of age on the effect of bidirectional cavopulmonary anastomosis on left ventricular volume, mass and ejection fraction. J Am Coll Cardiol 1996;28:1301-1307.[Abstract]
  16. Fontan F, Kirklin JW, Fernandez G, Costa F, Naftel DC, Tritto F, Blackstone EH. Outcome after a "perfect" Fontan operation. Circulation 1990;81:1520-1536.[Abstract/Free Full Text]
  17. Driscoll DJ, Offord KP, Feldt RH, Schaff HV, Puga FJ, Danielson GK. Five-to-fifteen year follow-up after Fontan operation. Circulation 1992;85:469-496.[Abstract/Free Full Text]
  18. Eicken A, Fratz S, Gutfried C, Balling G, Schwaiger M, Lange R, Busch R, Hess J, Stern H. Hearts late after Fontan operation have normal mass, normal volume, and reduced systolic function: a magnetic resonance imaging study. J Am Coll Cardiol 2003;42:1061-1065.[Abstract/Free Full Text]
  19. Fogel MA, Weinberg PM, Chin AJ, Fellows KE, Hoffmann EA. Late ventricular geometry and performance changes of functional single ventricle throughout staged Fontan reconstruction assessed by magnetic resonance imaging. J Am Coll Cardiol 1996;238:212-221.
  20. Senzaki H, Masutani S, Kobayashi J, Kogayashi T, Sasaki N, Asano H, Kyo S, Yokete Y, Ishizawa A. Ventricular afterload and ventricular work in Fontan circulation: comparison with normal two-ventricle circulation and single-ventricle circulation with Blalock–Taussig shunts. Circulation 2002;105:2885-2892.[Abstract/Free Full Text]
  21. Eicken A, Marek J, Vogel M, Hager A, Vogt M, Skovranek J, Busch R, Schreiber C, Hess J. Characteristics of Doppler myocardial echocardiography in patients with tricuspid atresia after total cavopulmonary connection with preserved systolic ventricular function. In J Cardiol 2007;116:212-218.[CrossRef]
  22. Gewillig MH, Lundstrom UR, Deanfield JE, Bull C, Franklin RC, Graham TP, Wyse RK. Impact of Fontan operation on left ventricular size and contractility in tricuspid atresia. Circulation 1990;81:118-127.[Abstract/Free Full Text]
  23. Rodriguez-Roisin R, Krowka MJ, Herve P, Fallon MB. Pulmonary-hepatic vascular disorders (PHD). Eur Respir J 2004;24:861-880.[Free Full Text]
  24. Hoeper MM, Krowka MJ, Strassburg CP. Portopulmonary hypertension and hepatopulmonary syndrome. Lancet 2004;363:1461-1468.[CrossRef][Medline]
  25. Praus A, Eicken A, Balling G, Schreiber C, Hess J. Progressive intrapulmonary shunting in a child after bidirectional Glenn operation only resolved after total cavopulmonary completion. Int J Cardiol 2008;128:e12-e15.[CrossRef][Medline]
  26. McFaul RC, Tajik AJ, Mair DD, Danielson GK, Seward JB. Development of pulmonary arteriovenous shunt after superior vena cava-right pulmonary artery (Glenn) anastomosis. Report of four cases. Circulation 1977;55:212-216.[Abstract/Free Full Text]




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