Surgical Options After Fontan Failure
What are surgical outcomes of Fontan takedown, Fontan conversion, and heart transplantation for failing Fontan patients in a multicenter experience?
A retrospective review was conducted by the European Congenital Heart Surgeons Association among 22 centers. The outcome of surgery for failing Fontan was collected in 225 patients, of which 17% underwent Fontan takedown, 61% Fontan conversion, and 22% heart transplant.
For patients undergoing re-operation, the most common indication was arrhythmia (43%), although indications differed based on surgical group. Fontan takedown was most commonly performed relatively soon after Fontan completion (median 0.6 ± 1.9 years). Mortality was particularly high for Fontan takedown, with 30-day mortality of 26%. Early mortality was 10.9% after Fontan conversion and 14% for heart transplant. The median follow-up for the entire cohort was 5.9 years (range 0-23.7 years). The combined endpoint of mortality/heart transplant was reached in 44.7% of Fontan takedown patients, 26.3% of the Fontan conversion patients, and 34% of the heart transplant patients (log rank p = 0.08). In patients undergoing Fontan conversion or heart transplant, ventricular systolic dysfunction appeared to be the strongest predictor of mortality or (re-)heart transplant.
The authors concluded that Fontan takedown is generally performed early in the postoperative period and is associated with high mortality. There is no difference in survival after Fontan conversion after heart transplant.
Although this study showed similar survival between cardiac transplantation and Fontan conversion, a direct comparison of these two groups is limited by significant differences in baseline characteristics. The patients undergoing heart transplant were more symptomatic, had greater left ventricular systolic dysfunction, and higher atrial pressures than those in the Fontan conversion group. If these patients had undergone Fontan conversion, their outcomes would not likely have been as good as those selected for Fontan conversion. This study also demonstrates extremely poor outcomes in patients requiring Fontan takedown. The need for Fontan takedown decreased over the study period, and is likely indicative of improved patient selection for Fontan over the course of the study period.
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