Transcatheter Fenestration Dilation and/or Creation in
Postoperative Fontan Patients
Jacqueline Kreutzer, MD, James E. Lock, MD,
I(BF)nintra-atrial
modified Fontan procedures, a surgically created
communication or baffle fenestration
has been shown to increase cardiac index, re-
duce right venous pressures, and decrease perioper-
ative and postoperative morbidity1 – 8 at the expense
of systemic desaturation. Subsequent BF closure can
be performed in most patients.1,9 When BF closure
occurs spontaneously, it may lead to hemodynamic
deterioration associated with elevated right-sided
pressures and high systemic oxygen saturation, low
cardiac output, progressive edema and effusions.
Therapeutic options for these severely ill patients are
few and of high risk (Fontan takedown or heart trans-
plantation).10 We report the results of a transcatheter
palliative approach for symptomatic postoperative
Fontan patients with total or virtual BF occlusion.
jjj
All patients (n Å 14) who underwent BF creation
and/or balloon dilation at Children’s Hospital, Bos-
ton, between January 1984 and August 1995 were
reviewed (Table I). Most had had Gore-Tex (Gore
and Associates, Newark, Delaware) punch BFs sur-
gically created measuring 4 mm (10 patients), 3 mm
(1 patient), and 2.5 mm (1 patient). Half of the pa-
tients presented acutely in the immediate postoper-
ative period (within 2 weeks, 3 hours to 14 days)
with low cardiac index (õ2 L/min/m2), prerenal fail-
ure with oliguria, hypotension (on intravenous ino-
tropes, as epinephrine and/or dopamine at ¢5 mg/kg/
min), on mechanical ventilation with high right atrial
pressures and systemic arterial partial pressure of ox-
ygen (PO2), generalized edema, and substantial chest
tube drainage. The remaining half presented with
chronic symptomatology at ¢2 weeks postopera-
tively (15 days to 5.4 years) with chronic effusions
requiring chest tube drainage and exercise intoler-
ance (New York Heart Association class III or IV)
(protein-losing enteropathy in 1 and atrial arrhyth-
mias in 2 patients). Echocardiograms obtained in 11
patients showed an absent or very small BF in all.
At catheterization (Tables II and III), following
complete hemodynamics, a Fontan baffle or right
atrial angiogram determined BF patency and size.
The BF was either completely occluded or absent (8
patients) or partially open (6 patients). In those pre-
senting °24 hours of surgery, the arterial PO2 on
inspired supplemental oxygen frequently exceeded
200 mm Hg. BF balloon dilation alone was per-
From the Departments of Cardiology and Cardiac Surgery, Children’s
Hospital, and the Departments of Pediatrics and Surgery, Harvard
Medical School, Boston, Massachusetts. Dr. Kreutzer’s address is:
Department of Cardiology, Children’s Hospital, 300 Longwood Av-
enue, Boston, Massachusetts 02115. Manuscript received March
21, 1996; revised manuscript received and accepted July 10,
1996.
228 Q1997 by Excerpta Medica, Inc.
All rights reserved.
/ 2w16 0711 Mp 228 Friday Dec 27 08:25 PM EL–AJC (v. 79, 2 ’97)
Richard A. Jonas, MD, and John F. Keane, MD
formed in 9 patients in whom a completely or vir-
tually closed BF could be crossed with a wire. An
end-hole catheter was then advanced in the left
atrium, a guidewire placed, and serial balloon dila-
tions performed using balloon catheters of increasing
diameter (3 to 8 mm), including high-pressure cath-
eters (Boston Scientific Co, Watertown, Massachu-
setts; Braun Medical Inc., Bethlehem, Pennsylvania;
Mallinckrodt Medical, St. Louis, Missouri), which
were almost always required. One patient had a Ber-
man catheter advanced through the BF and with-
drawn with the balloon inflated, without using an
angioplasty balloon.
A Brockenbrough transseptal puncture was per-
formed in 5 patients without a prior BF or in those
in whom it could not be crossed. The transseptal
sheath and dilator were then advanced through the
created baffle puncture site. Modifications of the nee-
dle curve were often required to traverse successfully
the Gore-Tex baffle. If there was difficulty in ad-
vancing the sheath, a wire was positioned into a pul-
monary vein via the dilator and followed by dilation
of the newly created orifice, using balloons of small
diameter initially (2 to 3 mm), followed by larger
ones, as required to increase the right to left shunt.
Among these were 2 patients with atriopulmonary
anastomoses and surgically closed atrial defects, in
whom balloons of 10 and 15 mm in diameter were
used, respectively. Of the 3 patients with a fenes-
trated lateral intra-atrial tunnel Fontan procedure
who underwent BF creation de novo, 1 presented
with high baffle pressures secondary to progression
of left pulmonary vein stenosis and had a 10-mm
renal Palmaz stent implanted straddling a newly cre-
ated BF with both ends flared, because only a very
small shunt could be obtained with dilation alone.
Aortic and mixed venous saturations, cardiac in-
dex, and pressures were recorded following each bal-
loon dilation. The procedure was concluded once
there was evidence of significant right to left shunt
by oximetry and angiographic demonstration of pat-
ent BF of adequate size. Procedural success was
achieved in 11 patients, arbitrarily considering a suc-
cessful procedure as that resulting in BF patency (¢3
mm) and an increase in the net right to left shunt
¢0.5. The dilation was unsuccessful in 3 patients, 1
of whom had elevated pulmonary vascular resis-
tance. Another patient with acute BF thrombosis 2
hours postoperatively developed marked cyanosis
after BF reopening, did not improve with the pro-
cedure, and died at Fontan takedown. The remaining
patient had atrial flutter and congestive heart failure
with ventricular dysfunction after atriopulmonary
anastomosis, did not improve after BF creation, and
died awaiting cardiac transplantation.
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 TABLE I Patient Characteristics
Age at BF Time Period
Patient Dilation Fontan-BF Clinical Procedural Follow-Up

/ 2w16 0711 Mp
Number Diagnosis Previous Fontan (yr) Dilation PO2 Presentation Success (mo) Later Outcome

1 DORV, mitral stenosis Fenestrated LT 5.1 1d 62 Acute 0 24 Fontan take down

229
hypoplastic left ventricle
2 Heterotaxy, DORV, pulmonary Fenestrated LT 2.9 3 mo 63 Chronic / 5 Death (progressive pulmonary
atresia, atrial situs inversus veins stenosis)
3 Straddling TV, multiple Fenestrated LT 2.1 1 mo 252 Chronic / Died 1 mo Death (neurologic complications)
ventricular septal defects, after
interrupted IVC
4 DILV, straddling TV, restrictive Fenestrated LT 0.8 2d 236 Acute / 40 Improved
BVF
5 DILV, straddling TV Fenestrated LT 3.4 6h 290 Acute / 26 Improved
6 DORV, superoinferior APA; TV & ASD 22.4 5.4 yr 338 Chronic (/ atrial 0 Died 3 mo Death (awaiting heart transplant)
ventricles closure arrhythmias) after
7 Tricuspid atresia type IIb, APA with conduit; 20.7 9.4 yr 339 Chronic / 48 Heart transplant; improved

Friday Dec 27 08:25 PM

transposition and ASD closure
pulmonary stenosis
8 Single DILV Fenestrated LT 4.6 20 d 68 Chronic / 19 Improved; BF closure 13 mo after
BF dilation
9 DOLV with hypoplastic right Fenestrated LT 4.9 2 yr 76 Chronic (/ PLE) / 16 Transient improvement
ventricle
10 HLHS, aortic atresia, mitral Fenestrated LT 0.9 1d 84 Acute / 17 Improved; Fontan reop.
atresia
11 Tricuspid atresia type IIb, Fenestrated LT 1.3 3h 240 Acute 0 Died Death at Fontan takedown
juxtaposed atrial same
appendages day

EL–AJC (v. 79, 2 ’97)

12 HLHS, mitral stenosis, aortic Fenestrated LT 1.7 16 d 72 Acute / 2 Improved
stenosis

0711
13 DORV, hypoplastic mitral Fenestrated LT 12.4 4 yr 48 Chronic (/ atrial / 4 Transient improvement;
valve, partial anomalous arrhythmias) progressive pulmonary vein
pulmonary veins to SVC stenosis
14 Tricuspid atresia type 1c Fenestrated LT 2.7 1d 193 Acute / 2 Improved
Median 3.1 139 17
Mean { SD 6.1 { 7.2 169 { 111 19 { 15

Acute Å acute presentation at °2 weeks postoperatively; APA Å atriopulmonary anastomosis; ASD Å atrial septal defect; BVF Å baffle fenestration; BF Å bulbo ventricular foramen; Chronic Å chronic presentation at ¢2 weeks postoperatively;
DILV Å double-inlet left ventricle; DOLV Å double-outlet left ventricle; DORV Å double-outlet right ventricle; HLHS Å hypoplastic left heart syndrome; IVC Å inferior vena cava; LT Å lateral intra-atrial tunnel used for total cavopulmonary anastomosis;
PLE Å protein-losing enteropathy; PO2 Å highest arterial partial pressure of oxygen on 80% to 100% forced inspiratory oxygen before transcatheter intervention; reop. Å reoperation; SVC Å superior vena cava; TV Å tricuspid valve.

BRIEF REPORTS
229

TABLE II Comparison of Cardiac Catheterization Data
(median values) Obtained Before and After Intervention
Before After
Cardiac index (L/min/m2)* 1.4 2.9
Oxygen saturation 93% 83%
PO2† 70 48.5
Net right to left shunt 0.05 0.8
Mean right atrial (mm Hg) 22 20.5
Mean BF gradient (mm Hg) 12 9 õ0.03
Mean blood pressure (mm Hg) 59.5 64
Fenestration diameter (mm) 0 (0–3) 4 (6–3)
* Based on measured (7 patients) or assumed oxygen consumption (7 intu-
bated patients).
†
Partial pressure of oxygen (PO2) measured in the cardiac catheterization
laboratory before and after intervention.
‡
By Wilcoxon-Rank test.
BF Å baffle fenestration.
Procedural complications included blood transfu-
sions (4 patients), severe cyanosis with hypotension
and bradycardia requiring resuscitation measures (1
patient), and a femoral artery pseudoaneurysm. There
were no ST-T-wave changes or other signs of possible
thromboembolic phenomenon. There were 4 deaths at
follow-up. One patient died at Fontan takedown and
another died from complications of postoperative
neurologic damage with severe choreoathetosis. The
patient who had had a stent implanted in the newly
created BF died with chronic effusions and right heart
failure associated with progressive stenosis of the left
pulmonary veins. No autopsy was performed. The
stent remained stable and patent by echocardiography
and at repeat catheterization 4 months after implan-
tation. This patient was managed with coumarin fol-
lowing stent implantation. The fourth patient, who
had had a newly created BF of the atrial septal defect
patch after atriopulmonary anastomosis, died 3
months later awaiting transplant in a chronic low car-
diac output state with atrial arrhythmias. Autopsy re-
vealed a patent 5-mm slit-like oval BF in the atrial
septum. Of the 10 survivors at follow-up, 3 patients
underwent reoperations including cardiac transplan-
tation, Fontan takedown, and Fontan reoperation, re-
spectively, because of baffle causing right pulmonary
vein compression. BF patency was confirmed preop-
eratively and/or at the time of surgery. Of the remain-
ing 7 patients, the BFs remained patent in 6, 2 of these
being occluded with a clamshell device without com-
plications 1 year later. These 6 patients continue with-
out effusions and all in New York Heart Association
class II or less. One patient with pulmonary vein
stents placed for severe and progressive pulmonary
vein stenosis is being evaluated for future heart-lung
transplantation. The patient who presented with pro-
tein-losing enteropathy had a 3-month period of im-
provement with decreased diuretic requirements, after
which spontaneous closure recurred followed by
worsening in the serum albumin. At follow-up, pa-
tients were taking either daily aspirin (4 patients, in-
cluding 1 with protein-losing enteropathy) or cou-
marin (3 patients).
230 THE AMERICAN JOURNAL OF CARDIOLOGYT
/ 2w16 0711 Mp 230 Friday Dec 27 08:25 PM
jjj
The effects of a BF in Fontan patients have been
well described.1 – 8 Most surgeons perform fenes-
p‡ trated Fontan procedures in complicated patients be-
Value
cause of the known advantages in reducing periop-
õ0.01 erative and postoperative morbidity by increasing
õ0.01 systemic cardiac output at the expense of a right to
õ0.01
õ0.01
left shunt. Tolerance for BF closure can be tested in
õ0.08 the cardiac catheterization laboratory with balloon
occlusion as previously reported.9 Some patients tol-
õ0.05 erate the BF test occlusion well, while others do not.
õ0.01
Thus, it is not surprising that when closure occurs
spontaneously, some patients develop severe hemo-
dynamic deterioration, while others experience no
clinical manifestations other than an increase in the
measured oxygen saturation. Among 182 patients
with fenestrated Fontan procedures performed at our
institution by April 1994, 35 had documented spon-
taneous BF closure at a mean follow-up time of 3.8
{ 1 year, giving an overall incidence of spontaneous
BF closure of 20% at 4 years, which probably un-
derestimates the true incidence. The precise time of
spontaneous closure is generally unknown, because
it is an asymptomatic phenomenon in most patients.
Among the 182 patients, 7 presented with acute life-
threatening symptoms after spontaneous complete or
virtual BF closure in the early postoperative period,
to the extent that the incidence of this occurrence is
3% to 4%. Of these 7 patients, 5 underwent trans-
catheter BF creation and/or dilation and are included
in this manuscript. The predisposing factors for
spontaneous closure are unknown, although the use
of antiplatelet therapy has been demonstrated to de-
lay closure in experimental animal studies with fen-
estrated atrial septal patches.10 In our report, spon-
taneous BF closure after reopening occurred in 1
patient at follow-up whose condition was managed
with low-dose aspirin.
The feasibility of BF balloon dilation has been
demonstrated by Nishimoto et al.11 In their report,
45 fenestrations (4 mm in diameter), created by a
punch as used when creating surgical BFs in poly-
tetrafluoroethylene patches, were dilated with 5 to 9
mm balloons after which they remained significantly
increased 2 weeks later. The first 3 patients under-
going BF reopening with transcatheter techniques
were included. Since then, our experience has ex-
panded to 14 patients, which represents the largest
series published on this subject. In this manuscript,
we demonstrate the feasibility and success rate of the
procedure, with a low incidence of procedural com-
plications. In addition, we describe BF creation de
novo via the Brockenbrough transseptal puncture of
the Fontan baffle or atrial septal patch, followed by
serial balloon dilations. One might expect BFs cre-
ated in this fashion to be slit-like rather than round,
similar to that resulting from dilation of a surgical
punch of the baffle.11 However, the 1 BF in this
study, which was observed at autopsy, was oval in
shape and 5 mm in diameter. In this study, we also
demonstrated that spontaneous BF closure can occur
very early postoperatively, and can be recognized by
VOL. 79 JANUARY 15, 1997
EL–AJC (v. 79, 2 ’97) 0711
 TABLE III Cardiac Catheterization Characteristics
Cardiac Index Fenestration Angiographic
(L/min/m2) O2 saturation (%) Right Atrial Pressure Gradient Diameter Right to Left Shunt Maximum
Patient Balloon
Number Before After Before After Before After Before After Before After Before After Size Used

1 1.2 1.9 83 73 26 25 8 7 2.5 4 0.2 0.5 5–2

2 1.8 2.8 88 61 25 24 18 18 0 6 0.1 1.3 5–2
3 2.4 ∗ 93 85 20 17 13 12 0 3 0 ∗ 6–2
4 2.5 3.4 98 83 20 17 9 7 0 4 0.4 1.3 4–2
5 2.5 3.5 77 72 13 16 8 10 2.5 4 1 1.9 7–2
6 2.8 2.9 95 92 18 14 10 8 0 4 0 0.2 10–2
7 1.3 2.4 96 76 26 22 12 8 0 4 0 1 15–2
8 2.5 3.2 91 84 22 22 12 9 2 4 0.3 0.8 5–2
9 2.8 3 96 85 14 ∗ 8 ∗ 1 4 0 0.9 5–2
10 1.1 2.8 93 83 22 24 9 6 0 4 0.1 0.8 7–2
11 1.4 ∗ 94 57 25 ∗ 12 ∗ 0 3 0 ∗ 5Fr Berman
12 1.2 2.6 92 80 17 19 6 5 0 4 0 0.5 8–2
13 2 3.4 92 87 26 22 18 14 3 5 0.2 0.9 5–2
14 1.3 2.6 99 93 24 16 16 6 0.5 4 0 0.5 8–2
t 2 { 0.7 2.8 { 0.6 91 { 7 79 { 11 21.3 { 4.4 19.8 { 3.7 12 { 4 9 { 4 0.8 { 1 4 { 0.7 0.2 { 0.2 0.9 { 0.4
* Data unavailable (not recorded).
t Å mean value { SD for all determinations.

high right atrial pressures, high arterial PO2 on in-
spired oxygen (ú200 mm Hg), fluid retention, ef-
fusions, and by echocardiography, and be alleviated
by interventional catheterization techniques.
Although a restrictive atrial septal defect serving
as a ‘‘safety valve’’ was incorporated in 2 of the first
atriopulmonary anastomoses performed in 1971,12
most such connections have been created without an
interatrial communication. In this small series, BF
creation in 2 such patients lead to no significant
symptomatic improvement. There was an immediate
increase in the cardiac index in 1 patient, in whom
BF creation may have played a role as short-term
palliation before transplantation. The remaining pa-
tient died without improvement awaiting transplan-
tation. In recognizing the limitations of this small
experience, the results seem to indicate that failing
patients with atriopulmonary anastomosis should be
considered for conversion to lateral tunnel total ca-
vopulmonary anastomosis or heart transplantation
rather than BF creation. However, improvement after
BF creation has been reported by others in 1 such
patient with protein-losing enteropathy.13
Nonfenestrated Fontan patients with protein-los-
ing enteropathy may be candidates for BF creation,
although there is limited experience with this group.
Only 1 such patient in this small series initially im-
proved, with normalization of serum albumin for ap-
proximately 4 months, after which BF spontaneous
closure and symptomatology recurred.
Even though the procedure was highly successful
and most patients had immediate improvement, a
patent and larger BF was not always associated with
long-term clinical improvement. There are many
variables influencing the clinical aspects of postop-
erative Fontan patients. Of those who improve after
BF dilation, some do not tolerate closure at a later
time and symptoms reappear if the BF closes. Pa-
tients who do not improve after creation of a BF and/
or dilation and require further surgical intervention
(takedown, reoperation, or transplantation) may have
transient hemodynamic benefit from the procedure
and improvement in the preoperative condition.
Some of the factors that contribute to failure after
BF occlusion may be transient, as evidenced by the
2 patients in this series who tolerated BF closure 1
year after BF creation.
The small number of patients limited our statis-
tical analyses, particularly in determining causative
factors and predictors of success. Although most pa-
tients significantly improved immediately after BF
creation or dilation, our conclusions are limited by
the absence of a control group and intercorrelation
of variables, such as additional interventions per-
formed, differences in medical therapies, and so
forth. In addition, our population was too small to
compare results of dilation of a preexisting surgical
BF with transcatheter BF creation de novo.
Spontaneous BF closure can occasionally be life
threatening, causing severely low cardiac index as-
sociated with elevation in oxygen saturations, pO2,
and right atrial pressures. Reopening of the BF in 14
such patients lead to dramatic hemodynamic im-
provement in most.
There are very few options for symptomatic
Fontan patients with an absent or occluded BF, all
involving significant mortality and risks (Fontan
takedown, Fontan baffle reoperation, and heart
transplantation).14 This report on the clinical use of
transcatheter BF creation and/or dilation in symp-
tomatic Fontan patients demonstrates feasibility
and safety of the procedure, presenting a novel
management option for these patients.
1. Bridges ND, Lock JE, Castañeda AR. Baffle fenestration with subsequent
transcatheter closure. Modification of the Fontan operation for patients at in-
creased risk. Circulation 1990;82:1681–1689.
2. Laks H, Pearl JM, Haas GS, Drinkwater DC, Milgalter E, Jarmakani JM,
Isabel-Jones J, George BL, Williams RG. Partial Fontan: advantages of an ad-
justable interatrial communication. Ann Thorac Surg 1991;52:1084–1094.

BRIEF REPORTS 231

/ 2w16 0711 Mp 231 Friday Dec 27 08:25 PM EL–AJC (v. 79, 2 ’97) 0711
3. Bridges ND, Mayer JE Jr, Lock JE, Jonas RA, Hanley FL, Keane JF, Perry
SB, Castañeda AR. Effect of baffle fenestration on outcome of the modified
Fontan operation. Circulation 1992;86:1762–1769.
4. Bridges ND, Castañeda AR. The fenestrated Fontan procedure. Hertz
1992;17:242–245.
5. Mavroudis C, Zales VR, Backer CL, Muster AJ, Latson LA. Fenestrated
Fontan with delayed catheter closure: effects volume loading and baffle fenes-
tration on cardiac index and oxygen delivery. Circulation 1992;86:(suppl II):II-
85–II-92.
6. Hijazi ZM, Fahey JT, Kleinman CS, Kopf GS, Hellenbrand WE.
Hemodynamic evaluation before and after closure of fenestrated Fontan.
An acute study of changes in oxygen delivery. Circulation 1992;86:196 –
202.
7. Kopf GS, Kleinman CS, Hizaji ZM, Fahey JT, Dewar ML, Hellenbrand WE.
Fenestrated Fontan operation with delayed transcatheter closure of atrial septal
defect. Improved result in high-risk patients. J Thorac Cardiovasc Surg
1992;103:1039–1048.
8. Harake B, Kuhn MA, Jarmakani JM, Laks H, Al-Katib Y, Elami A,
Williams RG. Acute hemodynamic effects of adjustable atrial septal defect
Optimal Albunex Dosing for Enhancement of Doppler
Tricuspid Regurgitation Spectra
W. Evans Kemp, Jr., MD, David M. Kerins, MD,
M any patients undergoing routine echocardio-
graphic examination have tricuspid regurgita-
tion (TR). Estimates of the frequency with which TR
is detected by Doppler echocardiography vary from
61% to 96% in patients with pulmonary hyperten-
sion and from 0% to 40% in patients with normal
pulmonary artery pressure.1 – 4 By adding estimated
central venous pressure to the spectral Doppler TR
gradient determined by the modified Bernoulli equa-
tion, P Å 4V2, pulmonary artery systolic pressure can
be calculated. Many patients do not have TR at
Doppler study or have trivial incomplete signals with
a poorly described envelope and peak velocity. Ag-
itated intravenous saline solution can reliably en-
hance these signals,5 – 7 but this technique is not
always successful, and the contrast effect is short-
lived. Albunex, an intravenous contrast agent com-
posed of albumin microbubbles, has also been shown
to enhance inadequate TR spectra effectively and to
provide a longer-lasting Doppler contrast effect than
that produced by saline.7 However, the optimal dose
of Albunex (Mallinckrodt Medical, Inc., St. Louis,
Missouri) for Doppler TR enhancement has not been
determined. We studied the efficacy of Albunex ver-
sus agitated saline for enhancing inadequate Doppler
TR spectra and determined the optimal dose of Al-
bunex for this application.
jjj
The study group consisted of 21 consecutive pa-
tients who underwent clinically indicated 2-dimen-
sional and Doppler echocardiography and were
found to have incomplete Doppler TR spectra, sig-
nals without well-defined borders or peaks. Patients
were excluded if they had a contraindication to the
From Vanderbilt University Medical Center, Nashville, Tennessee. Dr.
Kemp’s address is: Vanderbilt University Medical Center, 315 MRB
II, 2220 Pierce Avenue, Nashville, Tennessee 37232. Manuscript
received May 30, 1996; revised manuscript received and accepted
July 17, 1996.
232 Q1997 by Excerpta Medica, Inc.
All rights reserved.
/ 2w16 0711 Mp 232 Friday Dec 27 08:26 PM EL–AJC (v. 79, 2 ’97)
closure in the lateral tunnel Fontan procedure. J Am Coll Cardiol
1994;23:1671 – 1676.
9. Bridges ND, Lock JE, Mayer JE, Burnett J, Castañeda AR. Cardiac cathe-
terization and test occlusion of the interatrial communication after the fenes-
trated Fontan operation. J Am Coll Cardiol 1995;25:1712–1717.
10. Pearl JM, Laks H, Barthell S, Drinkwater DC Jr, Capouya ER, Chang PA.
Spontaneous closure of fenestrations in an interatrial Gore-Tex patch: applica-
tion to the Fontan procedure. Ann Thorac Surg 1994;57:611–614.
11. Nishimoto K, Keane JF, Jonas RA. Dilation of intra-atrial baffle fenestra-
tions: results in vivo and in vitro. Cathet Cardiovasc Diagn 1994;31:73–78.
12. Kreutzer G, Galindez E, Bono H, de Palma C, Laura JP. An operation for
the correction of tricuspid atresia. J Thorac Cardiovasc Surg 1973;65:613–621.
13. Mertens L, Dumoulin M, Gewillig M. Effect of percutaneous fenestration
of the atrial septum on protein-losing enteropathy after the Fontan operation.
Br Heart J 1994;729:591–592.
14. Knott-Craig CJ, Danielson GK, Schaff HV, Puga FJ, Weaver AL, Driscoll
DD. The modified Fontan operation. An analysis of risk factors for early post-
operative death or takedown in 702 consecutive patients from one institution.
J Thorac Cardiovasc Surg 1995;109:1237–1243.
Yu Shyr, PhD, and Benjamin F. Byrd III, MD
use of Albunex. The mean age was 52 { 13 years
(range 25 to 81); patients included 11 women and 10
men. The reason for examination included evalua-
tion of coronary artery disease/chest pain (n Å 8),
congestive heart failure/ cardiomyopathy (n Å 4),
known pulmonary hypertension (n Å 3), and other
conditions (n Å 6). Patients first provided written
informed consent approved by the institutional re-
view board. Then they underwent Doppler echocar-
diography during peripheral intravenous injection of
3 varying doses of either agitated saline or Albunex
in random order. An initial dose of 1 ml of undiluted
Albunex was given; subsequent doses were then ad-
justed upward or downward (range 0.25 to 4 ml),
depending on the amount of spectral distortion
(‘‘white-out’’ due to increased noise) seen with the
initial injection. Agitated saline was given in doses
of 1, 2, and 4 ml. A total of 6 injections was given.
Each agent was prepared using standard techniques
and product insert instructions. Each was delivered
via a 3-way stopcock into the right antecubital vein
(whenever possible) through a 20-gauge or larger
catheter. The injection rate was 1 ml/s, followed by
a flush with 10 ml saline. A baseline recording of the
spectral Doppler signal for TR was made before each
injection, with recording continued through the con-
trast effect until a return to baseline.
Echocardiographic studies were performed with
either an Acuson-128 or Hewlett-Packard Sonos
1500 instrument (Andover, Massachusetts). Contin-
uous-wave spectral Doppler recordings were made
with a 2.0-MHz duplex transducer and recorded on
S-VHS videotape for off-line analysis. Color Dopp-
ler was used to guide continuous-wave spectral
Doppler alignment for optimal signal recording.
Spectral Doppler gain settings were optimized before
injection and kept constant. Studies were interpreted
by 2 blinded observers. They were asked to deter-
mine which injections provided diagnostic Doppler
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