Novel method of surgical preparation for transcatheter completion of Fontan circulation: creation of an extracardiac pathway

Abstract

Background: The alliance between surgeons and interventionists has inspired creative techniques to surgically precondition the heart for subsequent transcatheter repair. The interest stems from the need to avoid repeated surgeries. Transcatheter Fontan completion of intracardiac pathway has been reported.

Aim: To report a new surgical preparation for transcatheter completion of extracardiac Fontan circulation.

Methods: The inferior vena cava (IVC) was cut and anastomosed end-to-end with the inferior end of a Gore-Tex conduit in 20 lambs. A ring was placed around the IVC near the anastomosis. The superior vena cava was cut and connected with the right atrium (RA) auricle. In group 1 (n=9), the Gore-Tex conduit was occluded at both ends by a polytetrafluoroethylene membrane. In group 2 (n=11), the upper segment of the Gore-Tex tube was opened and connected to the RA to allow free flow of IVC blood. Fontan completion was attempted 1-3 months following surgery. Animals were sacrificed just after or 3 months after completion.

Results: All lambs were successfully preconditioned. We failed to complete the pathway in all animals from group 1 - autopsy showed occlusion of the pathway. In group 2, there was one postoperative death, one elective sacrifice after 2 months to assess pathway integrity, and nine successful completions. Autopsies showed widely patent pathway and well-deployed covered stents completely occluding the fenestrations.

Conclusions: Circulating extracardiac conduit offers the best option to prepare for extracardiac Fontan completion. This surgical preparation opens new frontiers for transcatheter and hybrid techniques for extracardiac Fontan completion.

Keywords: Approches hybrides; Cardiopathies congénitales; Circulation de Fontan; Congenital heart defect; Fontan circulation; Hybrid approaches; Techniques percutanées; Transcatheter technique.