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<p><h1>THROMBOSIS AFTER A FONTAN OPERATION</H1> </p>
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<p>This is with regard to the question of anticoagulation for thrombosis following a Fontan type  operation.
	<p>In a recent editorial, (J.Thorac.Cardiovasc.Surg. 1995;110:1502-1503) Dr.Richard Jonas of Boston dealt with this problem. Some interesting points:
<p>	A 2.6% incidence of strokes among 645 patients who  had a Fontan operation at Childrens Hospital, Boston over a 15 year period.(du Plessis et al  Pediatr..Neurol.1995 ;12:230-6)
	<p>7 of the 17 patients had echo proven thrombi in intracardiac locations.....stump of main pulmonary artery, on a fenestrated right atrial baffle or lateral tunnel,and on the anterior mitral leaflet.</p>
<p>	Predisposing factors included <ul>
<li>		a. low cardiac output states
	<li>	b. design of the operation itself...stump of a large Pulm artery proximal to ligation (particularly in single ventricles with antegrade pulmonary blood flow) (ref:Rosenthal etal, J.Cardiovasc.Thorac.Surg .1995;110:1563-5), or a dilated right atrium after atriopulmonary anastomosis.
<li>		c. atrial flutter and fibrillation
	<li>	d. use of a fenestration (paradoxic embolus)
<li>		e. use of synthetic material for baffle</ul></p>
<p>	Regarding this last factor, an  interesting fact is that the  use of Goretex tube graft is better avoided for intracardiac tunnels.This graft has an OUTER WRAP ON THE ADVENTITIAL SURFACE which is NOT designed for blood contact and is thrombogenic. PTFE cardiovascular patch material is however designed for blood contact on both surfaces.
	<p>No prospective study has been done regarding anticoagulation after Fontan operation.  An empiric protocol followed at Boston Childrens Hospital is to prescribe anticoagulants to high risk groups such as
<ul><li>	1. prolonged hospitalization related to persistent pleural effusions
<li>	2. patients with chronically raised right atrial pressures.
	<li>3. patients with chronic borderline cardiac output.</ul>
<p>	All Fontan patients probably require careful long  term follow up with regular echocardiography to exclude development of cardiac thrombus.
	<p>Modifications of technique,as for instance, fully autogenous Fontan  operations,  will reduce this incidence.
<p>	Hope this helps</p>
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<ADDRESS> S.SIVASUBRAMANIAN/sivaraj@giasmd01.vsnl.net.in/Last reviewed on 14thJuly,1996</address>
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