A new surgical technique for transcatheter Fontan completion

Abstract

Objectives: Patients with complex congenital heart defects and univentricular heart usually required multiple palliative surgery aiming to separate pulmonary and systemic circulations. Various groups work on trying to perform the Fontan completion by a transcatheter technique. We developed and report here a modified technique to prepare the patient for this type of procedure.

Methods: Sixteen sheep were included and prepared through a midline sternotomy. Preparation for transcatheter completion was performed using specially designed devices. The superior vena cava (SVC) was connected to the pulmonary artery (PA) using a Goretex conduit. The connection between the SVC and the right atrium (RA) was interrupted using a vascular stent occluded in the middle by a polytetrafluoroethylene (PTFE) membrane. Two nitinol rings were placed around the inferior vena cava (IVC). Immediately after preparation, the transcatheter completion was performed by first perforating the membrane of the occluded stent and by placing covered stents from IVC rings to the SVC stent.

Results: Creation of the SVC to PA connection was uneventful. The insertion of the rings was done successfully in all animals very easily. All stents but one were completely occluding the SVC. Once, a tiny leak was noticed and successfully treated by additional stitches around the stent. Perforation of the membrane was done successfully in all animals re-establishing the pathway between the SVC and the RA. After dilatation of the stent, one animal required surgical control of a haemorrhage related to disruption of the SVC anastomosis. Three to four Cheatham-platinum (CP)-covered stents were necessary to complete the Fontan-like circulation. In the first animal, one stent moved downward missing its target. The placement between the two rings was easily performed using fluoroscopic guidance. No stents were positioned above the SVC stent keeping this part free of material.

Conclusions: We describe new improvements for surgical preparation for transcatheter completion of partial cavopulmonary connection. For superior connection, we developed an occluding stent that helps to re-establish RA to PA connection, alloys precise placement and enhances the stability of the completion stents. Inferiorly, anchorage of the covered stents is also improved by the use of nitinol rings.