Fontan Fenestration: To do or not to do?

Leaving a fenestration in the interatrial septum during a Fontan repair is useful in relieving the central venous congestion when pulmonary blood flow is driven by venous pressure in Fontan repair. Data from a multicenter Pediatric Heart Network has been published in JACC: Advances [1]. Subjects were between 2-6 years at Fontan surgery done between 2010 and 2020 with cardiac catheterization done within 1 year prior to the surgery. Fenestration was done in 465 of the 702 patients. Interestingly placement of fenestration was associated with center and Fontan type – whether it was lateral tunnel or extra cardiac. Shorter length of hospital stay after Fontan repair was noted in those who received a fenestration. They noted that benefit was more pronounced if mean pulmonary arterial pressure was 13 mm Hg or more, as expected.

An accompanying editorial discussed the matter further [2]. They noted the bias between centers and the type of operation, whether it was a lateral tunnel or extra cardiac conduit. Doing a fenestration during lateral tunnel type of repair was quite easy while doing it during extra cardiac conduit placement was ‘annoying’. During an extra cardiac conduit placement, placing a fenestration would mean aortic cross clamping and stopping the heart for placing a fenestration. This is reflected by the observation that while 96% of lateral tunnel cases received a fenestration while only half of the extra cardiac conduit cases received a fenestration. Authors of the editorial also noted that the cutoff of 13 mm Hg mean pulmonary artery pressure could not be taken as a great value, knowing how much venous pressure can vary with the level of hydration during cardiac catheterization. In their opinion, all patients would benefit from a fenestration, though it was technically more difficult to do it while doing an extracardiac conduit type of Fontan repair.

References

1. Garick D. Hill, Danny T.Y. Wu, M. Eric Ferguson, Saul Flores, Salil Ginde, Kevin D. Hill, Michael Johansen, Jane W. Newburger, Zhiqian Gao, and James F. Cnota. Preoperative Hemodynamics Impact the Benefit of Fenestration on Fontan Postoperative Length of Stay. JACC Adv. 2024 Mar, 3 (3) 100846.
2. Yves d’Udekem and Alyssia Venna. The Annoying Act of Creating a Fenestration.
   JACC Adv. 2024 Mar, 3 (3) 100844.