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PubMed1995

Renin, angiotensin II, and the development of effusions following bidirectional Glenn and Fontan procedures.

Pleural effusions are a troublesome complication following bidirectional Glenn and Fontan procedures. It was our hypothesis that effusions may be related to alterations in hormones that regulate fluid homeostasis. We made serial determinations (by radioimmunoassay) of antidiuretic hormone, cortisol, aldosterone, angiotensin II, and renin in patients undergoing bidirectional Glenn (n = 16) and Fontan procedures (n = 24). There were six patients who developed effusions following surgery. These patients had a different endocrinological pattern characterized by persistent elevation in renin (28 +/- 9 vs 9 +/- 5 ng/mL per hour, p < 0.01) and angiotensin II (110 +/- 33 vs 33 +/- 14 ng/L, p < 0.01) on the fifth postoperative day as compared to patients who did not develop effusions. These data demonstrate that patients who develop effusions following bidirectional Glenn and Fontan procedures have activation of their renin-angiotensin system.

Adolescent↗
PubMed2005

Anesthetic care during modified fontan procedure without cardiopulmonary bypass.

OBJECTIVE: The purpose of this study was to report the anesthetic care of patients during performance of a Fontan procedure without cardiopulmonary bypass (CPB). DESIGN: Retrospective chart review. SETTING: Operating room of a university hospital. PARTICIPANTS: Seven pediatric-patients undergoing inferior vena cava (IVC)-to-pulmonary artery (PA) anastomosis for completion of the Fontan procedure. INTERVENTIONS: Charts were reviewed for anesthetic technique, hemodynamic and ventilatory changes occurring during the procedure, and anesthetic interventions that were provided. MEASUREMENTS AND MAIN RESULTS: The off-bypass Fontan procedure was attempted in 7 patients (age: 26 months-7 years, weight: 13 to 28 kg). Exposure of the PA was not feasible in 1 patient because of a markedly enlarged right atrium. In the remaining 6 patients, before cross-clamping of the PA to allow for the proximal anastomosis between the PA and the conduit, alkalosis (pH > or =7.5) was maintained by the administration of sodium bicarbonate. After PA cross-clamping, fluid administration was necessary in 5 patients and dopamine (3-7 microg/kg/min) was necessary in 4 patients. The minute ventilation was increased by 18 +/- 7% to maintain baseline PaCO2 values. Before the placement of the PA cross-clamp, the end-tidal PaCO2 difference was 7 +/- 4 mmHg and the transcutaneous (TC)-PaCO2 difference was 3 +/- 2 mmHg. The end-tidal PaCO2 difference increased to 14 +/- 6 mmHg during cross-clamping of the PA, whereas no change was noted in the TC-PaCO2 difference. Once the proximal anastomosis was completed, a bridge was placed to redirect blood from the IVC to the right atrium while the IVC was clamped and attached to the distal end of the conduit. After placement of the distal end of the bridge into the IVC, fluid administration to maintain the blood pressure was necessary in 3 patients. In 1 patient, 20 minutes after placement of the bridge, the authors noted a progressive increase in the central venous pressure reading measured from the left femoral vein and the need for the administration of volume to maintain the mean arterial pressure. Examination of the bridge revealed occlusion with thrombus despite an activated coagulation time value of 250 to 300 seconds. The tracheas of 3 of the 6 patients were extubated in the operating room, whereas the other 3 were extubated in the pediatric intensive care unit within 4 hours of completion of the procedure. The 1 patient who required the use of CPB required reintubation and had a protracted intensive care unit course. The other 6 patients were discharged home on postoperative days 7 to 12. CONCLUSIONS: With alteration of the anesthetic technique, the Fontan procedure can be performed in selected patients without the need for CPB.

Anesthetics↗
PubMed2006

Successful ablation of atrioventricular nodal reentry tachycardia following the atriopulmonary Fontan procedure.

Arrhythmia is a prevalent complication of the atriopulmonary Fontan procedure, most commonly macro-reentrant tachycardia within the right atrium as a consequence of long-term morphological and haemodynamic changes coupled with surgical intervention. We describe a patient with a long history of supraventricular arrhythmia following the atriopulmonary Fontan procedure identified as atrioventricular nodal reentry tachycardia at electrophysiological assessment. Despite anatomical and technical difficulties related to right atrial morphological changes and loss of the tricuspid annulus with its associated anatomical landmarks, the arrhythmia was successfully ablated using a combined antegrade and retrograde mapping approach.

Adolescent↗
PubMed2003

Nitric oxide synthase expression by pulmonary arteries: a predictive marker of Fontan procedure outcome?

OBJECTIVES: We retrospectively analyzed lung biopsy specimens from patients who underwent the Fontan procedure to identify predictive markers of outcome. METHODS: We studied the intra-acinar pulmonary arteries present in lung biopsy specimens from 17 patients undergoing the Fontan procedure. We evaluated both their morphology and their expression of endothelial nitric oxide synthase and endothelin 1. We compared these data with those of 6 patients who died of no pulmonary cause (control group). RESULTS: Eight patients had a good surgical outcome (group 1). Their distal arteries were thin and weakly expressed endothelin 1 and endothelial nitric oxide synthase. The procedure failed in 9 patients (group 2). Their distal arteries displayed muscle extension with an increased wall thickness (P <.01 vs group 1). Their endothelin 1 expression remained low (not significant vs group 1). By contrast, endothelial nitric oxide synthase was markedly overexpressed (P <.001 vs group 1). CONCLUSION: Distal pulmonary arteries of patients in whom the Fontan procedure failed exhibited a markedly increased wall thickness and a clear endothelial nitric oxide synthase overexpression. In addition to giving clues to the pathogenesis of the procedure's failure, our study might help to define reliable predictive markers of its outcome.

Adolescent↗
PubMed2000

Serial assessment of left ventricular diastolic function after Fontan procedure.

OBJECTIVE: To assess longitudinal changes in systemic ventricular diastolic function late after the Fontan procedure. DESIGN AND PATIENTS: Prospective study of 13 patients at 2.8 (2.0) years (early) and again at 11.4 (2.0) years (late) after the Fontan procedure by Doppler echocardiography with simultaneous ECG, phonocardiogram, and respirometer. SETTING: Tertiary paediatric cardiac centre. RESULTS: The isovolumic relaxation time (IVRT) was significantly longer, and E wave deceleration time, E and A wave velocities, and E:A velocity ratio were reduced compared to normal both early and late after the procedure. The mean (SD) z score of IVRT decreased significantly from +2.50 (1.00) to +1.24 (0.80) (p = 0.002), and the z score of the E wave deceleration time decreased from -1.69 (1.31) to -2.40 (1.47) (p = 0.03) during follow up. The A wave deceleration time also tended to decrease (early 80 (12) ms v late 73 (11) ms, p = 0.13) with increased follow up. There were no changes of the E and A wave velocities and E:A velocity ratio. The E wave velocity was inversely related to IVRT both early (r = -0.82, p = 0.001) and late (r = -0.59, p = 0.034) after the operation. The prevalence of diastolic flow during isovolumic relaxation decreased from 85% (11/13) to 38% (5/13) (p = 0.04), while that of mid diastolic flow increased from 23% (3/13) to 77% (10/13) (p = 0.02) between the two assessments. CONCLUSIONS: Left ventricular diastolic function remains highly abnormal late after the Fontan procedure. The longitudinal changes demonstrated on follow up are compatible with reduction of left ventricular compliance in addition to persisting abnormalities of relaxation.

Blood Flow Velocity↗
PubMed1995

Conversion of the hemi-Fontan procedure to fenestrated total extracardiac cavopulmonary bypass.

BACKGROUND: Arrhythmias occur frequently after Fontan operations, and are related in part to high atrial pressure, wall distention, and scarring caused by extensive suture lines. These arrhythmic factors may be avoided by an extracardiac total cavopulmonary anastomosis. We have embarked on a program of conversion of the hemi-Fontan operation to a fenestrated extracardiac Fontan procedure with a relatively simple operation. METHODS: In a 4-month period ending in December 1994, 4 consecutive patients underwent this procedure. The inferior vena cava was divided and the cardiac end was oversewn. A large (20 to 25 mm) ascending aortic homograft, from which the inlet portion and valve had previously been excised, was interposed between the divided distal end of the inferior vena cava and the hood of the superior cavopulmonary anastomosis. A 4-mm fenestration with a pursestring snare mechanism was placed within the cavoatrial patch that had been implanted at the time of the hemi-Fontan procedure. RESULTS: There were no deaths, and the average length of stay was 12 +/- 4 days (range, 8 to 18 days). In early follow-up, there have been no atrial arrhythmias, and three of the four fenestrations have been documented to be patent. CONCLUSIONS: An extracardiac fenestrated Fontan procedure can safely and successfully be performed after a hemi-Fontan operation, and may have both hemodynamic and arrhythmic benefits.

Child↗
PubMed1999

Circumscribed intestinal protein loss with deficiency in CD4+ lymphocytes after the Fontan procedure.

UNLABELLED: Protein-losing enteropathy is an important complication after right heart bypass operations (Fontan procedure). Laboratory examinations usually reveal hypoalbuminaemia, hypoproteinaemia, elevated alpha(1)-antitrypsin clearance, and lymphocytopenia. A case of protein-losing enteropathy after Fontan procedure is reported with a circumscribed protein loss in the region of the terminal ileum despite good haemodynamics. The patient developed only mild hypoalbuminaemia and no diarrhoea but severe cellular and humoral immune abnormalities, namely a markedly decreased proportion of CD4+ lymphocytes but normal proportion of CD8+ lymphocytes (CD4+ 14%, CD8+ 23%) and decreased serum levels of immunoglobulin G. Intestinal biopsies revealed normal mucosa. This report is unique as it is the first to describe a ratio of CD4+ to CD8+ lymphocytes <1 due to an almost selective loss of CD4+ lymphocytes and a circumscribed intestinal protein loss in a patient who developed protein-losing enteropathy after Fontan operation. CONCLUSION: There is a severe decrease of CD4+ lymphocytes of unknown origin in a patient with circumscribed intestinal protein loss after Fontan operation. Passive leakage of lymph fluid due to abnormal systemic venous pressure is not a sufficient explanation of the almost selective loss of CD4+ lymphocytes. Primary or secondary activation of the immune system may influence structural integrity and permeability of the intestinal wall and may play a triggering role in protein-losing enteropathy after the Fontan procedure.

CD4 Lymphocyte Count↗
PubMed2000

Synthetic antifibrinolytics are not associated with an increased incidence of baffle fenestration closure after the modified Fontan procedure.

OBJECTIVE: To determine if the lysine analog antifibrinolytic agents, epsilon-aminocaproic acid and tranexamic acid, are associated with early closure of the baffle fenestration after the modified Fontan procedure. DESIGN: Retrospective chart review. SETTING: University hospital. PARTICIPANTS: Seventy-four successive patients underwent the modified Fontan procedure. Three patients received aprotinin and were excluded. A total of 71 patients were analyzed. INTERVENTIONS: Charts were examined for variables known to be associated with baffle fenestration closure in the modified Fontan procedure. MEASUREMENTS AND MAIN RESULTS: Occurrence of baffle fenestration closure, oxygen saturation, central venous pressure, left atrial pressure, transpulmonary gradient, chest tube drainage volume, chest tube drainage duration, intensive care unit (ICU) duration, and total inpatient duration were compared between the 33 patients who received antifibrinolytics and the 38 patients who did not. One patient of 71 had baffle fenestration closure in the first 48 hours after surgery. Oxygen saturation, central venous pressure, left atrial pressure, transpulmonary gradient, chest tube drainage volume, chest tube drainage duration, days in ICU, and total inpatient duration were not significantly different between the two groups. CONCLUSIONS: Use of epsilon-aminocaproic acid and tranexamic acid is not associated with early baffle fenestration closure after the modified Fontan procedure. It is concluded that these agents can be used without increasing the risk of spontaneous baffle fenestration closure.

Aminocaproic Acid↗
PubMedDate not supplied

Maximal hemodynamic response after the Fontan procedure: Doppler evaluation during the treadmill test.

After undergoing the Fontan procedure for congenital heart disease, 16 young patients performed a maximal treadmill test according to the Bruce protocol. The peak velocity of the blood flow in the ascending aorta, stroke index, and cardiac index were measured by continuous-wave Doppler echocardiography at rest and at each stage of the test. The results were compared with those from 18 normal children. The body surface area was similar in the two groups. The endurance time was 37% shorter in the Fontan group than in the control group. From the beginning of exercise until the sixth minute, the increase in stroke index was lower in the Fontan group (NS). After that point, the stroke index was maintained at a high level in the control group but decreased toward its original level in the Fontan group. The response of cardiac index to exercise in the two groups was comparable until the sixth minute, after which the Fontan group failed to maintain an ascending curve. All the hemodynamic values were significantly higher in the control group at maximal exercise; at this point the cardiac index had increased 79% in the Fontan group and 170% in the control group. The subnormal response of the stroke volume at submaximal exercise and the subsequent decrease at maximal exercise following the Fontan procedure are important hemodynamic findings.

Adolescent↗
PubMed1990

Role of lung biopsy in patients undergoing a modified Fontan procedure.

Fifty-six patients undergoing a modified Fontan procedure from 1977 to 1985 had lung tissue available from the perioperative period (n = 51) or recent palliative procedure (n = 5) (37 biopsy, 12 autopsy, 7 biopsy and autopsy). Twenty-six patients had tricuspid atresia, and 30 had other causes of functional univentricular heart. Pulmonary arterial structure was classified by both the Heath-Edwards and morphometric scales. Biopsy and autopsy grades were identical except for a minor difference in Heath-Edwards scale in one case. Elevated preoperative mean pulmonary artery pressure (greater than 15 mm Hg) was associated with medial hypertrophy (p = 0.04), although six patients with normal pulmonary artery pressure had medial hypertrophy and six patients with mean pulmonary artery pressure greater than 15 mm Hg did not have medial hypertrophy. Medial hypertrophy was a possible risk factor in patients with univentricular heart: Patients with medial hypertrophy had a ninefold greater risk of death (p = 0.08). Controlling for confounding variables did not alter this result (0.06 less than or equal to p less than or equal to 0.10). Medial hypertrophy was not a risk factor for death in patients with tricuspid atresia: Four had this feature and each survived. Four patients with tricuspid atresia died and none had medial hypertrophy. A mean transpulmonary pressure gradient was measured on the first postoperative day in 45 patients. In patients with medial hypertrophy there was a trend toward a higher gradient (p = 0.13). All patients with medial hypertrophy who had this measurement (n = 9) had a transpulmonary pressure gradient of 7 mm Hg or greater, whereas this was true in only 18 of 36 without medial hypertrophy (p = 0.007). On the basis of an evaluation of medial hypertrophy, we conclude that biopsy does not aid in selection of patients with tricuspid atresia for a Fontan procedure; its role in patients with univentricular heart is uncertain.

Adolescent↗
PubMed1997

Coagulation factor abnormalities after the Fontan procedure and its modifications.

OBJECTIVE: Recently we reported the prevalence of thromboembolism in patients who underwent the Fontan procedure and its modifications. Although hemodynamic factors may well contribute to thromboembolism, recent evidence suggests that coagulation factor abnormalities may also play a role. We therefore set out to investigate the coagulation status in a group of patients who had undergone the Fontan procedure. METHODS: The study population consists of 20 children who had undergone the Fontan procedure and its modifications. They were examined for coagulation factor abnormalities. Concentrations of serum albumin, total protein, and liver enzymes were also measured. The median age at the time of the operation was 6.2 years (17 months to 8 years) with a male/female ratio of 2.3:1. The median time from the Fontan repair was 4.9 years (18 to 76 months). RESULTS: Protein C (p < 0.001), protein S (p < 0.02), and factor VII (p < 0.001) were significantly lower than the normal range. The changes in serum albumin and total protein and factors II, IX, and X were not significant. CONCLUSIONS: It is possible that deficiency in protein C, protein S, and factor VII partly account for the prevalence of thromboembolism after Fontan-type repairs. The risk of long-term anticoagulation should be weighed against the best palliative procedure for these patients. We suggest that reduced protein C, protein S, and factor VII levels in this group of patients should be regarded as risk factors and that such patients should be treated with anticoagulants.

Child↗
PubMed1994

Thromboembolism after the Fontan procedure and its modifications.

The frequency of thromboembolism after the Fontan procedure has not been specifically addressed. Seventy patients underwent this operation between 1987 and 1992, and complete information was available on 64. Forty-five had a right atrium-pulmonary artery anastomosis, 17 had a total cavopulmonary connection, and 2 had a right atrium-right ventricle anastomosis. No patient received anticoagulants for more than 8 months postoperatively. Seven patients died in the early postoperative period (< 30 days). Ten cases of thromboembolism were identified in the follow-up, which ranged from 6 to 55 months (mean follow-up, 24.5 +/- 17 months). They occurred 7 days to 4.5 years after the Fontan repair. Seven thombi were on the systemic venous or pulmonary aspect of the circulation and three, on the systemic arterial aspect. Freedom from thromboembolism was 75% at 4 years. We conclude that thromboembolism is common after the Fontan procedure; it can occur several days to years postoperatively; it is an important cause of morbidity; and it may partly explain late death after the Fontan operation. Our data suggest that all patients undergoing this procedure require long-term anticoagulant therapy.

Anticoagulants↗
PubMed2005

Progression of liver pathology in patients undergoing the Fontan procedure: Chronic passive congestion, cardiac cirrhosis, hepatic adenoma, and hepatocellular carcinoma.

BACKGROUND: Staged palliative surgical procedures have been an effective treatment of complex congenital heart defects. The Fontan procedure has been of particular benefit to infants with functional single-ventricle complexes but with the consequence of a sustained increase of right-sided venous pressure. METHODS: We reviewed the clinical and pathologic features of 9 autopsied patients having undergone the Fontan procedure, with special attention given to their liver pathology. RESULTS: The 9 patients died from a few hours to 18 years after the Fontan operation. Chronic passive congestion was seen in 7 patients, and 4 patients surviving 4 to 18 years also had cardiac cirrhosis. Hepatic adenoma in the setting of cardiac cirrhosis was found in a patient surviving for 9 years. One patient surviving for 18 years had hepatocellular carcinoma superimposed on cardiac cirrhosis. Rupture of the hepatoma in this case led to fatal hemorrhage. CONCLUSION: The study shows that chronically increased hepatic venous pressure from the Fontan procedure might lead to chronic passive congestion, cardiac cirrhosis, hepatic adenoma, and hepatocellular carcinoma.

Adenoma↗
PubMed1980

Fontan procedure for tricuspid atresia.

A Fontan procedure has been performed on 29 patients for tricuspid valvular atresia. The age range was 8 months to 33 years (median 10 years), the pulmonary vascular resistance ranged from 1.8-6.1 units . m2 (mean 3.3 units . m2), and the mean pulmonary arterial pressure ranged from 13-45 mm Hg (mean 21 mm Hg). Twenty-nine previous operations had been performed in 23 patients. Fourteen other associated cardiopulmonary anomalies were present in 12 patients. There were four hospital deaths (13.8%), all in patients with complicating features. Among the last 22 consecutive patients who have undergone operation, one died (4.5%). Complete atrioventricular block necessitated pacemaker implantation in one patient. No late deaths occurred. Of the 19 patients followed 3 months or more from the time of operation, eight have no restriction of exercise capacity, nine have only mild restriction, and two have a poor result. The Fontan approach to tricuspid atresia has several theoretical advantages over previously used shunts or pulmonary artery banding, the operative mortality in patients who have suitable anatomy and hemodynamics is low, and the results have been good.

Adolescent↗
PubMed2001

Incidence and impact of systemic venous collateral development after Glenn and Fontan procedures.

BACKGROUND: Development of systemic venous collaterals after Glenn or Fontan procedures can lead to systemic desaturation and reduction in ventricular function, resulting in impaired everyday performance in patients with univentricular heart disease. METHODS: We analyzed 79 patients who had undergone a Glenn or Fontan procedure between 1995 and 1999 for the incidence and predilection sites of systemic venous collaterals as well as the therapeutic options. RESULTS: In 16/79 (= 20.2%) patients, 19 veno-venous connections were detected 310 days (1-966 days) postoperatively. Locations were: brachiocephalic angles/pericardial veins (7), azygos/hemiazygos system (5), Thebesian veins (2), epidiaphragmatic veins (5). Drainage was to the pulmonary veins in 5, to the "left" atrium in 9, and to the IVC system in 5 patients. An isolated intervention became necessary because of low saturations in 5/16 pts, with improvement in all of them (catheter embolization 4, surgical closure 1). CONCLUSIONS: After Glenn or Fontan operations, the increased central venous pressure may induce recanalization of embryologically preformed and obliterated vessels. Their predilection sites must be carefully evaluated pre- and postoperatively. During surgical procedures, potential venous channels should be ligated. Interventional or surgical closure of collaterals may become necessary.

Adolescent↗
PubMed1997

Enalapril does not enhance exercise capacity in patients after Fontan procedure.

BACKGROUND: Angiotensin-converting enzyme inhibitors improve exercise capacity in adults with congestive heart failure by decreasing systemic vascular resistance and improving ventricular diastolic function. Patients who have undergone the Fontan procedure have decreased cardiac output, increased systemic vascular resistance, abnormal diastolic function, and decreased exercise capacity compared with normal people. METHODS AND RESULTS: To test the hypothesis that afterload reduction therapy alters hemodynamic variables and augments exercise capacity in patients after a Fontan procedure, we compared the results of graded exercise with maximal effort from 18 subjects (14.5+/-6.2 years of age, 4 to 19 years after Fontan procedure) in a randomized, double-blind, placebo-controlled crossover trial using enalapril (0.2 to 0.3 mg x kg[-1] x d[-1], maximum 15 mg). Each treatment was administered for 10 weeks. Diastolic filling patterns at rest were assessed by Doppler determination of the systemic atrioventricular valve flow velocity at the conclusion of each therapy. No difference was detected in resting heart rate, blood pressure, or cardiac index. Diastolic filling patterns were also similar. Exercise duration was not different (6.4+/-2.6 [enalapril] versus 6.7+/-2.6 minutes [placebo]). The mean percent increase in cardiac index from rest to maximum exercise was slightly but significantly decreased in subjects after 10 weeks of enalapril therapy (102+/-34% [enalapril] versus 125+/-34% [placebo]; P<.02). At maximal exercise, cardiac index (3.5+/-0.9 [enalapril] versus 3.8+/-0.9 L x min[-1] x m2 [placebo]), oxygen consumption (18.3+/-9 [enalapril] versus 20.5+/-7 mL x min[-1] x kg[-1] [placebo]), minute ventilation (57.5+/-17 [enalapril] versus 55.4+/-19 L/min [placebo]), and total work (247+/-181 [enalapril] versus 261+/-197 W [placebo]) were not different. CONCLUSIONS: We conclude that enalapril administration for 10 weeks does not alter abnormal systemic vascular resistance, resting cardiac index, diastolic function, or exercise capacity in patients who have undergone a Fontan procedure.

Adolescent↗
PubMed1997

The Fontan procedure in adults.

BACKGROUND: A retrospective clinical study was performed to document the course of adult patients undergoing the Fontan procedure. METHODS: Between 1982 and 1994, 21 adults aged 18 to 40 years (mean age, 27 +/- 7 years) underwent a Fontan procedure. Anatomic diagnosis was tricuspid atresia in 9, double-inlet left ventricle in 4, and various single ventricles in 8. Four underwent a right atria-right ventricle connection, 13 had a right atria-pulmonary artery connection, and 4 had a lateral-tunnel Fontan. Three of these 4 had a snare-adjustable atrial septal defect. Preoperative risk factors assessed were left ventricular end-diastolic pressure greater than 10 mm Hg, ejection fraction lower than 0.45, mean pulmonary artery pressure higher than 15 mm Hg, transpulmonary gradient greater than 10 mm Hg, pulmonary artery abnormalities, and atrioventricular valve regurgitation. Mean preoperative risk score was 1.6 /-1.1. Mean New York Heart Association class was 2.6 +/- 0.5. RESULTS: The operative mortality rate was 5% (1/21). Six patients (30%) had a major complication, four being prolonged effusions. One patient was lost to follow-up; the remaining 20 have been followed for a mean of 7.4 +/- 3.8 years. At follow-up, mean New York Heart Association class was 1.7 +/- 0.5. There has been one late death (5%) at 9 2/3 years, which was probably due to ventricular arrhythmia. Three patients (16%) have required and survived reoperation. During follow-up, 7 patients (37%) have had development of atrial arrhythmias requiring medication, and 2 have been treated for ventricular arrhythmias. CONCLUSIONS: These results indicate that properly selected adults can undergo the Fontan procedure with low morbidity and mortality. However, late-developing arrhythmias, need for reoperation, and decreasing ventricular function are serious problems that mandate careful follow-up.

Adult↗
PubMed1994

Comparison of the hormonal response after bidirectional Glenn and Fontan procedures.

Fluid retention is a frequent complication after the bidirectional Glenn and Fontan procedures. It was our hypothesis that this fluid retention may have a hormonal basis. To test this hypothesis, we made serial determinations of antidiuretic hormone, cortisol, aldosterone, angiotensin, and renin before and after operation in patients undergoing a bidirectional Glenn (n = 15) or Fontan (n = 18) procedure. Patients undergoing a bidirectional Glenn procedure had elevations in antidiuretic hormone, cortisol, and aldosterone immediately after operation. However, none of the hormonal elevations persisted by the fifth postoperative day. In contrast, patients undergoing a Fontan procedure had elevations in antidiuretic hormone, cortisol, aldosterone, renin, and angiotensin II in the immediate postoperative period. Five days postoperatively, the renin and angiotensin II levels remained elevated compared with the preoperative values. The data demonstrate that patients undergoing a bidirectional Glenn procedure and those undergoing a Fontan procedure have different patterns of hormonal response. These results suggest that hormonal factors may contribute to fluid retention after these operations.

Aldosterone↗