Hemidiaphragmatic paralysis increases postoperative morbidity after a modified Fontan operation

AbstractObjectives: After a Fontan procedure, forward pulmonary blood flow is augmented during inspiration because of negative intrathoracic pressure. Total pulmonary blood flow is higher during inspiration. With hemidiaphragmatic paralysis, inspiratory augmentation of pulmonary flow is lost or diminished. The objective of this study was to compare early postoperative morbidity after the modified Fontan operation in patients with and without hemidiaphragmatic paralysis. Methods: A case-control analysis was performed comparing 10 patients with documented hemidiaphragmatic paralysis against 30 patients without paralysis who were matched for diagnosis, fenestration, and age. The following early postoperative outcomes were assessed: duration of ventilator support, duration of hospital stay, incidence of ascites, prolonged effusions, and readmission. Results: Preoperatively, there were no significant differences between the 2 groups. However, among the postoperative outcomes, the duration of hospital stay (25.4 ± 16.6 days vs 10.8 ± 6.3 days; P =.03), incidence of ascites (70% vs 3%; P ||.001), prolonged pleural effusions (60% vs 13%; P =.007), and readmission (50% vs 7%; P =.007) were significantly greater in patients with hemidiaphragmatic paralysis than in those without hemidiaphragmatic paralysis. Conclusions: Hemidiaphragmatic paralysis after the modified Fontan operation is associated with an increase in early morbidity. Care should be taken to avoid injury to the phrenic nerve. Patients with prolonged effusions should be evaluated for hemidiaphragmatic paralysis.J Thorac Cardiovasc Surg 2001;122:856-6

Pulmonary artery growth after bidirectional cavopulmonary shunt: Is there a cause for concern?

AbstractObjective: Our objective was to analyze changes in pulmonary artery size after bidirectional cavopulmonary shunt. Methods: All 47 patients who underwent bidirectional cavopulmonary shunt between March 1990 and May 1995 who had preoperative and postoperative angiograms available for review were selected for study. This included 24 patients who had also undergone a modified Fontan operation. Clinical records were reviewed retrospectively and cross-sectional follow-up was obtained by direct physician contact. Angiograms were reveiwed, and the right and left pulmonary artery diameters were each measured at two locations: immediately distal to their origin and at the narrowest point. In addition, the lower lobe pulmonary artery branch was measured just distal to its origin. Cross-sectional areas (left, right, and total) at each point of measurement were indexed to body surface area. Angiographic and hemodynamic data were analyzed. Results: Changes in the various measures of pulmonary artery size after bidirectional cavopulmonary shunt varied considerably. On average the absolute diameters increased for all measures, but the increase in diameter was significant only for the lower lobe arteries. All pulmonary artery indices decreased on average, but these changes did not approach significance. Patients who underwent pulmonary artery augmentation at the time of bidirectional cavopulmonary shunt had significantly smaller pulmonary artery indices before pulmonary artery augmentation, relative to those who did not undergo pulmonary artery repair, and significantly greater changes (possibly to a large extent owing to pulmonary artery repair) in the right and left pulmonary artery index after bidirectionl cavopulmonary shunt. Lower lobe indices did not differ preoperatively or exhibit different degrees of change in size between patients who did and did not undergo pulmonary artery repair. One patient died after Fontan completion (pulmonary artery index: 305 mm2/m2), and none of the factors analyzed correlated with Fontan outcomes. Conclusions: A more appropriate measure of pulmonary artery growth is the indexed cross-sectional area of the lower lobe branch of the right and left pulmonary arteries, which is less likely to be altered surgically with systemic-pulmonary shunts, pulmonary artery repair, and the bidirectional cavopulmonary anastomosis itself. Pulmonary artery indices, including the lower lobe index, do not change significantly after bidirectional cavopulmonary shunt during medium-term follow-up and do not influence the Fontan outcome. (J THORAC CARDIOVASC SURG 1996;112:1180-92