Brachial arteriovenous fistula in patients with cavopulmonary connection and poor ventricular function: A bridge to Fontan operation

Objective: Augmentation of pulmonary blood flow is the only surgical treatment to reduce symptoms of cyanosis in patients with cavopulmonary connection unsuitable for Fontan operation. Brachial arteriovenous fistula is a good option to increase pulmonary blood flow. In this report, we analyze its possible consequences on ventricular function. Methods: Six patients considered unsuitable for a Fontan completion because of poor ventricular function underwent brachial arteriovenous fistula. The fistula was performed with the interposition of a 4-mm gore-tex conduit between the brachial vein and the brachial artery. Results: The mean oxygen saturation increased from 76.8 ± 1.9% to 84.1 ± 1.4% (p < 0.01); hemoglobin and hematocrit decreased from 21.13 ± 0.7 g/dL to 18.12 ± 0.5 g/dL (p < 0.01) and from 63.3 ± 2.7% to 54.2 ± 0.7% (p < 0.01), respectively. Mean ejection fraction and shortening fraction increased from 38.6 ± 1.5% to 49.5 ± 2.3% (p < 0.01) and from 23.3 ± 1.8% to 28.8 ± 1.3% (p < 0.01), respectively. A Fontan completion and takedown of the fistula was then accomplished, within six years, with no mortality or major complications. At a mean follow-up of 15 months, all six patients are clinically in good condition. Conclusion: In patients with a cavopulmonary connection and poor ventricular function, the brachial arteriovenous fistula may play a role in increasing oxygen saturation, optimizing ventricular preload, and reducing blood viscosity and pulmonary arteriovenous malformations. This approach might represent an intermediate step to rescue patients previously considered unsuitable or at high risk for Fontan operation.