First Fontan Procedure

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Introduction
Fontan and Baudet detailed in their article the first Fontan procedure in the early seventies [1]. Since then, the Fontan procedure has been applied for palliation of single ventricle (SV) patients. Multiple modifications of the original procedure were introduced to improve morbidity and mortality. Short and long term outcomes of the Fontan procedure were studied heavily by numerous investigators [2, 3]. Wellbeing of SV patients, following Fontan palliation, going into adolescent and adulthood was the core of multiple meetings in the 21th century. This kind of meetings was dictated by the need for modified care plans suitable for the growing number of adult patients who underwent this palliative procedure [4-7].
One of the risk
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The internal mammary artery (IMA) is used in almost every patient undergoing CABG surgery. IMA, especially LIMA, is the cardiac surgeons’ blood vessel of choice due to superior long-term patency compared to other used vessels [12, 13]. IMA is strikingly resistant to the development of atherosclerosis secondary to its superior endothelial function. Endothelial function is the balance between the endothelium-derived relaxing and contracting factors. It is proven that the endothelial-dependent relaxation is much greater in the IMA compared to other venous grafts used in CABG [17,18]. Coiling a vessel that has such enormous ability to stay patent is a common practice in all centers dealing with SV patients, particularly during the pre-Fontan cardiac catheterization. The goal of such practice is to optimize the outcome for the Fontan procedure by unloading the SV. Our study showed that half of the SV patients at our center received coiling of IMA and most of these patients had their collaterals coiled during the pre-Fontan cardiac catheterization (Figure 1). These patients had the optimum circumstances for successful Fontan procedure and post Fontan outcome. On the other hand, they were permanently deprived from the best and the most commonly used vessel for their prospect potential CABG …show more content…
Likewise, there is continuous novel thinking that may lead to a paradigm shift in the management of SV patients (22). Nevertheless, until a new modality is available, preservation of every possible vessel that might be required in potential future treatment of SV patients should be entertained. Coiling of IMAs has to be performed when extremely indicated. Multi-center, prospective study is needed for further verification of the frequency of IMA coiling nationwide. Accordingly, modification of the Society of Thoracic Surgeons database to specify which IMAs received coiling in SV patients is suggested or

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