Abstract
In patients with Fontan circulation, the conduit may be punctured for electrophysiological procedures. We evaluated the feasibility and safety of a stepwise approach to conduit puncture in adults who have undergone Fontan operation.
We included 13 consecutive patients with lateral tunnel or extracardiac conduit Fontan circulation [median age (interquartile range), 24.0 (16.0–25.0) years; seven men] who had undergone electrophysiological procedures. We performed a stepwise approach to conduit puncture: 1st, Brockenbrough needle; 2nd, Brockenbrough needle with snare; 3rd, extra-steep Brockenbrough needle with/without snare; 4th radiofrequency transseptal needle with/without snare; 5th, wiring through the puncture; 6th, conduit dilation with angioplasty balloon; 7th, non-compliant or cutting balloon; and 8th, Inoue dilator. In 12 patients, conduit puncture was successful. In two, one, and two patients with a lateral tunnel made of the pericardium or right atrial wall, conduit puncture was performed by steps 1st, 2nd, and 4th, respectively. In one, three, two, and one patient with the Goretex lateral tunnel or extracardiac conduit, conduit puncture was performed by steps 1st, 6th, 7th, and 8th, respectively. Puncture time was significantly longer in patients with Goretex conduits than with pericardial conduits [62.0 (50.0–120.0) and 11.5 (10.0–14.8) min, respectively; P < 0.001]. A snare was necessary in patients with angles ≤ 35° between the conduit wall and vertical line.
A stepwise conduit puncture approach is feasible and safe in patients with lateral tunnel and extracardiac conduit Fontan circulation. Goretex conduit puncture was more difficult than pericardial conduit puncture.
What’s new?
A stepwise approach to Fontan conduit puncture is feasible and safe in patients with lateral tunnel and extracardiac conduit Fontan circulation.
The level of difficulty of conduit puncture depends on the material of the conduit. Goretex conduit puncture is more difficult than pericardial conduit puncture.
Holding the dilator tip of the introducer by a snare is helpful for preventing the dilator tip from sliding along the conduit wall during conduit puncture in patients with a vertical conduit wall.
Introduction
Due to developments in surgery and interventions and advances in medication, the survival rate and life expectancy of patients with congenital heart diseases have been increasing.1,2 During long-term follow-up of adults with congenital heart disease, arrhythmias and heart failure have become emerging problems.2,3 Consequently, the necessity to perform electrophysiological studies and place cardiac implantable electronic devices is increasing in these patients. The Fontan operation is a palliative procedure for patients with a functional single ventricle.4,5 As a type of revised Fontan operation, a total cavopulmonary connection using the lateral tunnel or the extracardiac conduit has been performed.6 The Fontan conduit is usually made of autologous pericardium or Goretex. Electrophysiological procedures are challenging in patients with lateral tunnel and extracardiac Fontan conduits, because the caval veins are not directly drained into the heart. The objective of this study was to demonstrate the feasibility and safety of a stepwise approach to conduit puncture for electrophysiological procedures in adult patients who have undergone lateral tunnel or extracardiac conduit Fontan operation.
Methods
The study design was approved by the institutional review board and was conducted in compliance with the Declaration of Helsinki. Informed consent and a critical event committee were exempted by the board because this was a retrospective study. We included 13 consecutive patients [age, 24.0 (16.0–25.0) years; seven men] with lateral tunnel or extracardiac conduit Fontan circulation who had undergone electrophysiological study or pacemaker implantation from December 2013 to January 2017 (Table 1). Seven and six patients had lateral tunnel and extracardiac conduits, respectively. Five patients had a lateral tunnel conduits made of autologous pericardium or right atrial wall. Two patients had a lateral tunnel conduit made of Goretex. Five and one patient had an extracardiac conduits made of Goretex and autologous pericardium, respectively. In 12 patients, an electrophysiological study was performed. In one patient, a DDDR pacemaker was implanted via Fontan conduit puncture for sick sinus syndrome.7
Baseline characteristics and electrophysiological procedures of each patient
| Number | Age (year) | Sex | Fontan conduit | Conduit material | CHD | IVC location | Arrhythmia | Anglea (°) | Puncture methodb | Puncture time (min) | Result |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 14 | M | LT | pericardium | DILV, TGA | Right | Septal AT | 33 | 4th step | 10 | Success |
| 2 | 31 | M | ECC | Goretex | DORV, VSD | Right | SSS | 29 | 6th step | 62 | Success |
| 3 | 16 | F | ECC | pericardium | MA, TGA | Left | NCT | 47 | 10 | Failure to puncture | |
| 4 | 16 | F | LT | pericardium | DORV, AVSD | Right | AVNRT | 29 | 2nd step | 20 | Success |
| 5 | 26 | F | ECC | Goretex | TGA, VSD | Right | Scar-related AFL | 26 | 6th step | 59 | Success |
| 6 | 25 | M | LT | Goretex | Crisscross, TGA | Right | Scar-related AFL | 30 | 7th step | 120 | Success |
| 7 | 19 | M | LT | pericardium | PA with IVS | Right | Conduit AT | 41 | 1st step | 13 | Success |
| 8 | 24 | M | ECC | Goretex | DORV, TA | Right | Unusual AVNRT | 24 | 8th step | 134 | Failure to ablate |
| 9 | 17 | M | LT | atrial wall | TA with VSD | Right | AT | 44 | 4th step | 12 | Success |
| 10 | 24 | F | LT | pericardium | FSV | Right | PAF | 40 | 1st step | 11 | Success |
| 11 | 24 | F | ECC | Goretex | AVSD, right isomerism | Right | AVRT via twin AVN | 57 | 6th step | 50 | Success |
| 12 | 25 | M | LT | Goretex | AVSD, DORV, dextrocardia | Left | AVRT | 40 | 1st step | 25 | Success |
| 13 | 7 | F | ECC | Goretex | TA with VSD, AVSD | Left | AVRT via twin AVN | 51 | 7th step | 110 | Success |
| Number | Age (year) | Sex | Fontan conduit | Conduit material | CHD | IVC location | Arrhythmia | Anglea (°) | Puncture methodb | Puncture time (min) | Result |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 14 | M | LT | pericardium | DILV, TGA | Right | Septal AT | 33 | 4th step | 10 | Success |
| 2 | 31 | M | ECC | Goretex | DORV, VSD | Right | SSS | 29 | 6th step | 62 | Success |
| 3 | 16 | F | ECC | pericardium | MA, TGA | Left | NCT | 47 | 10 | Failure to puncture | |
| 4 | 16 | F | LT | pericardium | DORV, AVSD | Right | AVNRT | 29 | 2nd step | 20 | Success |
| 5 | 26 | F | ECC | Goretex | TGA, VSD | Right | Scar-related AFL | 26 | 6th step | 59 | Success |
| 6 | 25 | M | LT | Goretex | Crisscross, TGA | Right | Scar-related AFL | 30 | 7th step | 120 | Success |
| 7 | 19 | M | LT | pericardium | PA with IVS | Right | Conduit AT | 41 | 1st step | 13 | Success |
| 8 | 24 | M | ECC | Goretex | DORV, TA | Right | Unusual AVNRT | 24 | 8th step | 134 | Failure to ablate |
| 9 | 17 | M | LT | atrial wall | TA with VSD | Right | AT | 44 | 4th step | 12 | Success |
| 10 | 24 | F | LT | pericardium | FSV | Right | PAF | 40 | 1st step | 11 | Success |
| 11 | 24 | F | ECC | Goretex | AVSD, right isomerism | Right | AVRT via twin AVN | 57 | 6th step | 50 | Success |
| 12 | 25 | M | LT | Goretex | AVSD, DORV, dextrocardia | Left | AVRT | 40 | 1st step | 25 | Success |
| 13 | 7 | F | ECC | Goretex | TA with VSD, AVSD | Left | AVRT via twin AVN | 51 | 7th step | 110 | Success |
AFL, atrial flutter; AT, atrial tachycardia; AVN, atrioventricular node; AVNRT, atrioventricular nodal re-entrant tachycardia; AVRT, atrioventricular re-entrant (or reciprocating) tachycardia; AVSD, atrioventricular septal defect; BRK, Brockenbrough; CHD, congenital heart disease; ECC, extracardiac conduit; DILV, double-inlet left ventricle; DORV, double-outlet right ventricle; F, female; FSV, functional single ventricle; IVS, intact ventricular septum; LT, lateral tunnel; M, male; MA, mitral atresia; NC, non-compliant; NCT, narrow QRS complex tachycardia; PA, pulmonary atresia; PAF, paroxysmal atrial fibrillation; RF, radiofrequency; SSS, sick sinus syndrome; TA, tricuspid atresia; TGA, transposition of the great arteries; VSD, ventricular septal defect.
Angle between the Fontan conduit wall and vertical line
Puncture methods are described in Figure3.
Baseline characteristics and electrophysiological procedures of each patient
| Number | Age (year) | Sex | Fontan conduit | Conduit material | CHD | IVC location | Arrhythmia | Anglea (°) | Puncture methodb | Puncture time (min) | Result |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 14 | M | LT | pericardium | DILV, TGA | Right | Septal AT | 33 | 4th step | 10 | Success |
| 2 | 31 | M | ECC | Goretex | DORV, VSD | Right | SSS | 29 | 6th step | 62 | Success |
| 3 | 16 | F | ECC | pericardium | MA, TGA | Left | NCT | 47 | 10 | Failure to puncture | |
| 4 | 16 | F | LT | pericardium | DORV, AVSD | Right | AVNRT | 29 | 2nd step | 20 | Success |
| 5 | 26 | F | ECC | Goretex | TGA, VSD | Right | Scar-related AFL | 26 | 6th step | 59 | Success |
| 6 | 25 | M | LT | Goretex | Crisscross, TGA | Right | Scar-related AFL | 30 | 7th step | 120 | Success |
| 7 | 19 | M | LT | pericardium | PA with IVS | Right | Conduit AT | 41 | 1st step | 13 | Success |
| 8 | 24 | M | ECC | Goretex | DORV, TA | Right | Unusual AVNRT | 24 | 8th step | 134 | Failure to ablate |
| 9 | 17 | M | LT | atrial wall | TA with VSD | Right | AT | 44 | 4th step | 12 | Success |
| 10 | 24 | F | LT | pericardium | FSV | Right | PAF | 40 | 1st step | 11 | Success |
| 11 | 24 | F | ECC | Goretex | AVSD, right isomerism | Right | AVRT via twin AVN | 57 | 6th step | 50 | Success |
| 12 | 25 | M | LT | Goretex | AVSD, DORV, dextrocardia | Left | AVRT | 40 | 1st step | 25 | Success |
| 13 | 7 | F | ECC | Goretex | TA with VSD, AVSD | Left | AVRT via twin AVN | 51 | 7th step | 110 | Success |
| Number | Age (year) | Sex | Fontan conduit | Conduit material | CHD | IVC location | Arrhythmia | Anglea (°) | Puncture methodb | Puncture time (min) | Result |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 14 | M | LT | pericardium | DILV, TGA | Right | Septal AT | 33 | 4th step | 10 | Success |
| 2 | 31 | M | ECC | Goretex | DORV, VSD | Right | SSS | 29 | 6th step | 62 | Success |
| 3 | 16 | F | ECC | pericardium | MA, TGA | Left | NCT | 47 | 10 | Failure to puncture | |
| 4 | 16 | F | LT | pericardium | DORV, AVSD | Right | AVNRT | 29 | 2nd step | 20 | Success |
| 5 | 26 | F | ECC | Goretex | TGA, VSD | Right | Scar-related AFL | 26 | 6th step | 59 | Success |
| 6 | 25 | M | LT | Goretex | Crisscross, TGA | Right | Scar-related AFL | 30 | 7th step | 120 | Success |
| 7 | 19 | M | LT | pericardium | PA with IVS | Right | Conduit AT | 41 | 1st step | 13 | Success |
| 8 | 24 | M | ECC | Goretex | DORV, TA | Right | Unusual AVNRT | 24 | 8th step | 134 | Failure to ablate |
| 9 | 17 | M | LT | atrial wall | TA with VSD | Right | AT | 44 | 4th step | 12 | Success |
| 10 | 24 | F | LT | pericardium | FSV | Right | PAF | 40 | 1st step | 11 | Success |
| 11 | 24 | F | ECC | Goretex | AVSD, right isomerism | Right | AVRT via twin AVN | 57 | 6th step | 50 | Success |
| 12 | 25 | M | LT | Goretex | AVSD, DORV, dextrocardia | Left | AVRT | 40 | 1st step | 25 | Success |
| 13 | 7 | F | ECC | Goretex | TA with VSD, AVSD | Left | AVRT via twin AVN | 51 | 7th step | 110 | Success |
AFL, atrial flutter; AT, atrial tachycardia; AVN, atrioventricular node; AVNRT, atrioventricular nodal re-entrant tachycardia; AVRT, atrioventricular re-entrant (or reciprocating) tachycardia; AVSD, atrioventricular septal defect; BRK, Brockenbrough; CHD, congenital heart disease; ECC, extracardiac conduit; DILV, double-inlet left ventricle; DORV, double-outlet right ventricle; F, female; FSV, functional single ventricle; IVS, intact ventricular septum; LT, lateral tunnel; M, male; MA, mitral atresia; NC, non-compliant; NCT, narrow QRS complex tachycardia; PA, pulmonary atresia; PAF, paroxysmal atrial fibrillation; RF, radiofrequency; SSS, sick sinus syndrome; TA, tricuspid atresia; TGA, transposition of the great arteries; VSD, ventricular septal defect.
Angle between the Fontan conduit wall and vertical line
Puncture methods are described in Figure3.
Before the electrophysiological study, cardiac computed tomography (CT) was performed on all patients in order to identify the cardiac and vascular anatomy and perform three-dimensional electroanatomical mapping (Figure 1). The appropriate puncture site and Brockenbrough needle direction were estimated based on cardiac CT images. Patients underwent the electrophysiological study while in a fasting state and under local anaesthesia with sedation or general anaesthesia. A quadripolar catheter was placed in the ventricle through a retrograde aortic approach. A quadripolar catheter was placed in the conduit via the femoral vein or in the oesophagus at the level of the atrium for recording atrial signals and atrial pacing. If the atrium could not be paced with the lead in the oesophagus or the conduit, a deflectable quadripolar catheter was placed into the atrium through the femoral artery, aorta, ventricle, and atrioventricular (AV) valve. If the coronary sinus opened into the Fontan conduit, a decapolar catheter was placed into the coronary sinus through the inferior vena cava and Fontan conduit. In some cases, a deflectable quadripolar catheter was placed on the cusp of the aortic valve to record the His bundle signal. If electrocardiography (ECG) revealed sinus rhythm at the beginning of an electrophysiological study, programmed electric stimulations with/without isoproterenol infusion were conducted for tachycardia induction. After inducibility of tachycardia was confirmed, an intracardiac echocardiography catheter was inserted into the Fontan conduit through the femoral vein. Fontan conduit angiography was performed and the angle between the Fontan conduit wall and the vertical line was measured (Figure 2A). We began performing Fontan conduit puncture using a stepwise approach. A stepwise approach to Fontan conduit puncture is comprised of four stages and nine steps: needling, wiring, puncture dilation, and introducer insertion stages (Figure 3). In the 1st step, we used a Brockenbrough needle (BRK-1 or BRK; St. Jude Medical, Minnetonka, MN, USA) and a Swartz introducer (SR-0 or SL-1; St. Jude Medical). If the dilator tip of the Swartz introducer slid along the conduit wall during the puncture attempt, it was held with a gooseneck snare catheter (PFM Medical, Nonnweiler, Germany) as the 2nd step (Figure 2B and C). If the 2nd step failed, we used an extra-steep Brockenbrough needle (XS series; St. Jude Medical) as a 3rd step. If the 3rd step failed, we used a radiofrequency transseptal needle (Baylis Medical Company, Montreal, Canada) as a 4th step. If the conduit wall seemed to be hard, an extra-steep Brockenbrough needle or a radiofrequency transseptal needle could be used as the initial step, according to operator’s discretion. During the needling stage, the Brockenbrough needle position and cardiac anatomy at the puncture level were visualized with intracardiac echocardiography (Figure 2D). While normal saline or contrast was injected through the Brockenbrough needle, puncture or not was confirmed by observation of bubbles with intracardiac echocardiography. If the introducer could not be inserted into the atrium via the puncture site after conduit puncture, we inserted a 0.014-inch wire into the atrium via the Brockenbrough needle as a 5th step. We dilated the conduit puncture with angioplasty balloons (≥ 4.5 mm in diameter for a non-steerable introducer and ≥6.0 mm in diameter for a steerable introducer) as a 6th step (Figure 4C). If the 6th step failed, we dilated the conduit puncture with non-compliant or cutting balloons as a 7th step. If the 7th step failed, we used the dilator for an Inoue balloon (Toray Corporation, Tokyo, Japan) as an 8th step (Figure 4D). If the Swartz introducer could be inserted into the atrium through the conduit puncture as a 9th step and an endpoint of conduit puncture, we performed an electrophysiological study and catheter ablation with conventional mapping techniques and three-dimensional electroanatomical mapping system. During the procedure, the activated clotting time was maintained between 300 and 350 s by heparin infusion. After the procedure, oral anticoagulation therapy was maintained for at least 3 months. The conduit puncture time was recorded for each patient. Major complications associated with conduit puncture were defined as haemopericardium (or cardiac tamponade), stroke, and vascular access site bleeding that required transfusion.
Cardiac computed tomography of patients with lateral tunnel Fontan conduit made of autologous pericardium (A), and extracardiac Fontan conduit made of Goretex (B). F, Fontan conduit.
Fontan conduit puncture in a patient with extracardiac conduit Fontan circulation made of Goretex. (A) Fontan conduit angiography. (B) Fluoroscopic image obtained while performing conduit puncture with a Brockenbrough needle and holding the dilator tip with a snare. (C) Intracardiac echocardiography of the conduit puncture. (D) The Brockenbrough needle and the Swartz introducer with the dilator tip held with a snare to prevent its sliding along the conduit wall. A, atrium; F, Fontan conduit; ICE, intracardiac echocardiography; LPA, left pulmonary artery; V, ventricle; θ, angle between the Fontan conduit wall and vertical line.
A stepwise approach to Fontan conduit puncture: four stages and nine steps.
Fluoroscopic images of Fontan conduit puncture in a patient with extracardiac conduit Fontan circulation made of Goretex. (A) Fontan conduit angiography. (B) Conduit puncture with a radiofrequency transseptal needle with holding the dilator tip with the snare. (C) Balloon dilation of the conduit puncture with an angioplasty balloon. (D) Dilation of the conduit puncture with a dilator of an Inoue balloon. A, atrium; F, Fontan conduit; ICE, intracardiac echocardiography; IVC, inferior vena cava; LPA, left pulmonary artery; RPA, right pulmonary artery; RF, radiofrequency; V, ventricle; θ, angle between the Fontan conduit wall and vertical line.
Statistical analysis
Continuous data were presented as medians (interquartile ranges). We compared puncture time according to conduit materials using the Mann–Whitney U-test. Spearman’s correlation analysis was used to compare conduit puncture time and the duration between the Fontan operation and an electrophysiological procedure. A P-value < 0.05 was considered significant. The data were analysed using the Statistical Package for the Social Sciences, version 23.0 (IBM Inc., Armonk, NY, USA).
Results
The time between Fontan operation and development of tachycardia was 15.5 (9.5–18.1) years. In 12 of 13 patients, Fontan conduit puncture via the right femoral vein was successful and without complications. In two and one patient with lateral tunnels made of autologous pericardium and Goretex, respectively, conduit puncture was successfully performed by using the 1st step. In one patient with a lateral tunnel made of autologous pericardium, conduit puncture was successfully performed using the 2nd step. In two patients with lateral tunnels made of autologous pericardium or right atrium, conduit puncture was successfully performed with the 4th step. In three patients with extracardiac conduits made of Goretex, conduit puncture was successfully performed with the 6th step. In one and one patient with a lateral tunnel and extracardiac conduit made of Goretex, respectively, conduit puncture was successfully performed with the 7th step. In one patient with an extracardiac conduit made of Goretex, conduit puncture was successfully performed with the 8th step. In one patient with an extracardiac conduit made of autologous pericardium, conduit puncture failed due to the interruption of both femoral veins. In that case, we tried to puncture the conduit via the right jugular vein, but failed due to an unfavourable angle between the superior vena cava and the conduit wall.
Conduit puncture time was significantly longer in patients with conduits made of Goretex than in patients with conduits made of autologous pericardium or atrial wall [62.0 (50.0–120.0) and 11.5 (10.0–14.8) min, respectively; P < 0.001]. There was no significant association between duration since Fontan operation and puncture time (P = 0.601). A snare was used in all patients with an angle of ≤ 35° between the Fontan conduit wall and the vertical line (Figure 2A, 4A, and5A). In contrast, a snare was not used in patients with an angle > 35° between the Fontan conduit wall and the vertical line. However, in a patient (Number 13) with levocardia and the left inferior vena cava, a snare was used although the angle was 51°. It was because the Fontan conduit was not aligned with the left inferior vena cava line (Figure 5).
Fluoroscopic images of Fontan conduit puncture in a patient with extracardiac conduit Fontan circulation and the left inferior vena cava. (A) Fontan conduit angiography. (B) Conduit puncture with a Brockenbrough needle with holding the dilator tip with the snare. F, Fontan conduit; ICE, intracardiac echocardiography; IVC, inferior vena cava; LPA, left pulmonary artery; θ, angle between the Fontan conduit wall and vertical line.
In 12 patients in whom conduit puncture was successful, radiofrequency catheter ablation or pacemaker implantation was performed. There were no major complications during and after the procedures. We performed intracardiac echocardiography 9 months after Fontan conduit puncture in a patient (Number 10) with the lateral tunnel made of autologous pericardium. We found that the prior conduit puncture was closed.
Discussion
The present study showed that a stepwise approach for conduit puncture was feasible and safe for patients with lateral tunnel or extracardiac conduit Fontan circulation. Goretex conduit puncture was more difficult and took more time than did puncture of conduits made of pericardium or right atrium. Holding the dilator tip of the introducer by a snare was helpful for preventing the dilator tip from sliding along the conduit wall during conduit puncture in patients with a vertical conduit wall.
Because the caval veins are not directly connected to the heart in patients with lateral tunnel or extracardiac conduit Fontan circulation, Fontan conduit puncture is necessary for performing electrophysiological procedures.8,9 According to the present study, the level of difficulty of conduit puncture depends on the material of the conduit, and not on conduit age or type. Therefore, many devices, including radiofrequency transseptal needles, various kinds of wires and angioplasty balloons, and Inoue dilators should be prepared for patients with Goretex Fontan conduits. In addition, a snare can be needed for patients with a vertical conduit wall or the left inferior vena cava. It is reasonable to perform the stepwise approach to Fontan conduit puncture after confirming tachycardia inducibility by programmed electric stimulation in patients with sinus rhythm at the beginning of an electrophysiological study. Radiofrequency transseptal needles and angioplasty balloons are useful in patients with fibrosis around the conduit.10–12 Because the outer diameter of the non-steerable Swartz introducer is about 4 mm, an angioplasty balloon of ≥4.5 mm in diameter is acceptable for conduit puncture dilation.13 Because the steerable introducer is thicker than the non-steerable introducer, an angioplasty balloon of ≥6.0 mm in diameter is acceptable for the steerable introducer. In patients with vertical conduit wall, the transseptal needle tends to slide along the conduit wall instead of puncturing it. This issue can be overcome by holding the dilator tip of the Swartz introducer with a snare catheter.14 A snare is also useful in patients with the left inferior vena cava. In addition, left femoral vein approach is more favourable than right femoral vein approach for Fontan conduit puncture in patients with the left inferior vena cava. It is because the Brockenbrough needle in the left inferior vena cava is straighter through the left femoral vein than the right femoral vein. An XS-series Brockenbrough needle has a sharper tip than the usual type of a Brockenbrough needle does. It is useful for puncturing fibrotic septum. Conduit puncture through a region of overlap between the inferior vena cava and atrium is possible in some patients.15 However, the cavoatrial overlap region can be lacking in some patients who have undergone conversion surgery from atriopulmonary connection or lateral tunnel Fontan circulation to extracardiac conduit Fontan circulation in adulthood.
Preprocedural cardiac CT is useful for identifying cardiac and vascular anatomy and planning puncture sites and the Brockenbrough needle direction. Sternal suture wires can be a useful landmark during conduit puncture under fluoroscopy. During the needling stage, intracardiac echocardiography is essential during conduit puncture because it shows real-time, high-resolution images. With intracardiac echocardiography, we can obtain information on the Brockenbrough needle position and intracardiac anatomy at the puncture level.
After Fontan conduit puncture, oral anticoagulation therapy needs to be maintained because small thrombi from the veins of the lower extremities can cross to systemic circulation via the conduit puncture.16 The duration of oral anticoagulation therapy remains undetermined, because data on the natural closure of Fontan conduit punctures are lacking. Further studies are necessary to understand when Fontan conduit punctures close.
Study limitations
The number of patients in the present study was small. The stepwise approach to Fontan conduit puncture needs to be tested in a large number of patients by many operators in other arrhythmia centres.
Conclusions
A stepwise approach to conduit puncture is feasible and safe in patients with lateral tunnel and extracardiac Fontan circulation. Goretex conduit puncture is more difficult than pericardial conduit puncture.
Conflict of interest: none declared.
