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What is a ventricle? Morphologic lessons from the Fontan circulation

IN THE ACCOMPANYING REPORT, 1 MURARI AND colleagues give a detailed analysis of the morphologic findings within the hearts of a large number of patients they chose to correct surgically by creating a circulation in which flow to the lungs is no longer driven by a ventricle. This, of course, is the situation produced by the Fontan procedure and its various modifications. Description of the ventricular mass in such patients produces potential problems since, although the pulmonary circulation does not have the benefit of its own ventricle to provide systolic propulsion, it is unusual for the patients treated in this fashion to have a solitary ventricular chamber. Indeed, I was involved in a very similar study to this one when I spent a period in Melbourne in 1992, working with Jim Wilkinson and his colleagues. When we analyzed the ventricular morphology of the patients submitted to the Fontan procedure in Melbourne, we obtained data from 138 patients. Of these, only five possessed a ventricular mass made up of a solitary chamber. In the others, 84 had two ventricular chambers, but with the atrioventricular junctions arranged so that one of the chambers was obviously rudimentary and incomplete. In the remaining 49 patients, however, each atrial chamber was connected to its own ventricle, and some other morphologic anomaly had prevented the surgeon attempting a biventricular repair. Findings such as this are by no means unusual, and are virtually replicated in the experience from New Delhi. In their series of 240 patients undergoing a Fontan-type repair, only 3 possessed a truly solitary ventricle, considered by them to be of indeterminate morphology. Of the remaining