Single Ventricle Surgery: Fontan Operation – The Children’s Hospital of Philadelphia (5 of 6)


>>THE THIRD-STAGE OPERATION
IS A VARIANT OF THE FONTAN OPERATION.>>AND THAT GENERALLY TAKES
PLACE SOMEWHERE AFTER TWO YEARS, BUT THE CHILD’S
PHYSIOLOGY REALLY TELLS US THE BEST TIME TO DO THAT.>>THERE ARE TWO TYPES
OF FONTAN OPERATIONS. ONE IS CALLED THE
LATERAL TUNNEL FONTAN, IN WHICH A BAFFLE IS PLACED
INSIDE THE HEART TO REDIRECT THE BLOOD FLOW FROM THE
LOWER PART OF THE BODY TO THE LUNGS. THE OTHER IS CALLED THE
EXTRA CARDIAC FONTAN, WHERE WE ACTUALLY USE A
TUBE THAT BRINGS THE BLOOD OUTSIDE THE HEART, UP TO
THE PULMONARY ARTERIES.>>BUT THE FONTAN OPERATION
IS BASED ON CONNECTING THE VEINS FROM THE BODY DIRECTLY
TO THE ARTERIES TO THE LUNGS.>>NORMALLY, THE
INFERIOR VENA CAVA, WHICH DRAINS THE
BOTTOM OF THE BODY, ATTACHES TO THE HEART AT THE
INFERIOR OR BOTTOM PORTION. AND WHAT WE DO IS TO
LITERALLY DIVIDE THIS FROM THE HEART. WE SEW UP THE PORTION OF
THE HEART WHERE THE INFERIOR VENA CAVA ENTERED, AND THEN
WE SEW A TUBE END-TO-END TO THE REMNANTS OF THE
INFERIOR VENA CAVA. WE TAKE THIS TUBE AND
LOOP IT AROUND THE SIDE OF THE HEART AND SEW IT
INTO A HOLE WE MAKE INTO THE PULMONARY ARTERY. SO WE ESSENTIALLY
BYPASS THE ENTIRE HEART.>>IT’S A MORE EFFICIENT
CONNECTION BECAUSE THE TUBE IS A VERY SPECIFIC SIZE,
AND THE BLOOD GOING THROUGH THERE IS NOT TURBULENT. TURBULENCE LOSES POWER,
AND POWER LOSS IS A PROBLEM IF YOU DON’T HAVE ANYTHING
PUSHING BLOOD THROUGH THE LUNGS. IT CANNOT WORK UNLESS
THERE’S LOW RESISTANCE IN THE LUNGS. AND THE KEY IS YOU HAVE TO
HAVE A GOOD PUMPING CHAMBER ON THE OTHER SIDE WHICH
ESSENTIALLY SORT OF SUCKS BLOOD THROUGH THE LUNGS.>>NOW, THE ONE MODIFICATION
IS THAT WE PUT A SMALL HOLE IN THE SIDE OF THE HEART AND
IN THE SIDE OF THIS GRAFT AND SEW IT TOGETHER
WITH WHAT’S CALLED A FENESTRATION.>>AND THE REASON WE DO THAT
IS THAT IT’S BEEN SHOWN THAT HAVING THAT LITTLE HOLE,
WHILE IT DOES ALLOW SOME BLUE BLOOD TO MIX
WITH THE RED BLOOD, IT ALSO DECREASES THE RISK
OF DEVELOPING FLUID AROUND THE LUNGS AFTER SURGERY,
SOMETHING CALLED A PLURAL EFFUSION. EFFUSIONS USED TO BE THE
BIGGEST PROBLEM AFTER THE FONTAN OPERATION. CHILDREN WOULD HAVE THE
SURGERY AND DO QUITE WELL, BUT THEY WOULD DEVELOP A
LOT OF FLUID THAT COLLECTED AROUND THE LUNG, AND THEY’D
OFTEN HAVE TO HAVE A TUBE IN THE CHEST FOR WEEKS OR EVEN
MONTHS TO DRAIN THAT FLUID. NOWADAYS, WITH THE USE
OF THIS FENESTRATION, THAT IS A VERY
UNCOMMON EVENT, WHEREAS IT USED
TO BE ROUTINE.

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