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Late reoperations for Fontan patients: state of the art invited review
Constantine Mavroudis1, Carl Lewis Backer, Barbara J Deal
1Division of Cardiovascular-Thoracic Surgery, Department of Surgery, Children's Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL 60614, USA. cmavroudis@childrensmemorial.org
Insights
Fontan conversion to total cavopulmonary extracardiac connection is safe and effective for patients with arrhythmias. This surgical strategy evolved to treat various atrial and ventricular tachycardias, improving outcomes.
Area of Science:
- Cardiology
- Cardiac Surgery
- Electrophysiology
Background:
- The Fontan procedure is a palliative surgery for complex congenital heart disease.
- Atriopulmonary Fontan connections can lead to arrhythmias and suboptimal hemodynamics.
- Conversion to a total cavopulmonary connection aims to improve long-term outcomes.
Purpose of the Study:
- To evaluate the safety and efficacy of converting atriopulmonary Fontan to total cavopulmonary extracardiac connection.
- To describe the surgical strategies for concomitant arrhythmia management during Fontan conversion.
- To present solutions for complex cases with anatomical and pathophysiological variations.
Main Methods:
- Retrospective review of 118 patients undergoing Fontan conversion from 1994 to 2007.
- Surgical techniques included extracardiac conduit, arrhythmia ablation, and pacemaker implantation.
- Management of various atrial and ventricular arrhythmias was detailed.
Main Results:
- Low early (0.8%) and late (7.6%) mortality rates were observed.
- Successful treatment of macro re-entrant atrial tachycardia, focal atrial tachycardia, AVNRT, and atrial fibrillation.
- Effective management of ventricular tachycardia and complex anatomical variations.
Conclusions:
- Fontan conversion to total cavopulmonary extracardiac connection is a safe and effective procedure.
- Concomitant arrhythmia surgery and pacemaker placement are crucial for optimal results.
- The described surgical strategies offer solutions for complex patient populations.
Abstract:
Conversion of the atriopulmonary Fontan to a total cavopulmonary extracardiac connection with concomitant arrhythmia surgery and pacemaker placement is a safe and efficacious procedure for this patient population. From 1994 to 2007 a total of 118 patients have undergone this procedure with one (0.8%) early and nine (7.6%) late deaths. During the course of our experience with Fontan conversion our surgical strategy has evolved to include various ablative techniques to treat macro re-entrant atrial tachycardia, focal (automatic) atrial tachycardia, atrioventricular nodal reentry tachycardia, atrial tachycardia due to accessory connections, atrial fibrillation, and ventricular tachycardia. The various mechanisms that we use to treat the underlying atrial arrhythmias are described in this review. We have also encountered patients with variations of the Fontan and other complex anatomic and pathophysiologic aberrations who were not amenable to standard takedown and ablative procedures. We describe those circumstances and the solutions we found to treat those patients.