Use of Heart Positioning Device During Extracardiac Fontan Procedure

The Fontan procedure remains the final palliative procedure for all functional single ventricle patients. Since 1968, when it was introduced, the Fontan procedure has undergone many modifications. Extracardiac conduit (ECC) Fontan involves direct connection of the superior vena cava (or cavae) to the pulmonary arteries, mostly as a previous bidirectional Glenn procedure and placement of an interposition tube graft outside of the heart, from the inferior vena cava to the pulmonary vasculature. ECC Fontan in the current era is mostly done with normothermic cardiopulmonary bypass with a bicaval cannulation without cardioplegia on beating heart (1). Being a part of a staged procedure, Fontan procedures are mostly redo procedures, and significant intrapericardial adhesions are the norm. The inferior vena cava (IVC) needs to be cannulated low to aid in ease of anastomosis. This involves significant dissection and mobilization near the IVC. Also, during the anastomosis, especially the IVC part, the ventricular mass needs to be retracted with retraction sutures near the acute margin of the heart or with the help of surgical assistant’s hands (1).

Heart positioning devices have been used in off-pump coronary artery bypass. This video demonstrates the use of a heart positioning device (Starfish®, Medtronic Inc., Minneapolis, Minnesota, USA) during an extracardiac Fontan procedure to retract the ventricular mass away safely, thereby facilitating the IVC anastomosis.

Not only does the use of the device make the retraction of the ventricular mass easier and safer, it also keeps the surgical assistant’s hands free to help during the surgery. In Fontan with apicocaval juxtaposition, where the ventricular apex is right on the IVC area, this becomes even more relevant. This simple extension of the use of a heart positioning device in Fontan procedure can aid in making the IVC area more accessible and the anastomosis easier.

References

1. Bradley, SM .Extracardiac conduit Fontan procedure. Oper Tech Thoracic Cardiovasc Surg. 2006,11(2):123–140.
2. Kogon, B. Is the extracardiac Conduit the preferred Fontan approach for patients with univentricular hearts? Circulation. 2012;126:2511-2515.

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