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Fontan conversion: identifying the high-risk patient
Sameh M Said1, Harold M Burkhart1, Hartzell V Schaff1
1Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
Insights
Fontan conversion candidates require careful selection. Older age and atrioventricular valve regurgitation increase Fontan conversion risks, suggesting cardiac transplantation may be better for some patients.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Congenital Heart Disease
Background:
- Patients with atriopulmonary Fontan connections often require conversion to total cavopulmonary connections due to arrhythmias or poor hemodynamics.
- Identifying ideal candidates for Fontan conversion remains a challenge.
Purpose of the Study:
- To evaluate outcomes of Fontan conversion procedures.
- To identify predictors of mortality and factors influencing successful conversion.
Main Methods:
- Retrospective analysis of 70 patients undergoing Fontan conversion between 1994 and 2011.
- Analysis included patient demographics, diagnoses, pre-operative conditions (arrhythmias, valve regurgitation), surgical techniques, and outcomes.
- Multivariate analysis was used to identify predictors of perioperative death.
Main Results:
- Early mortality was 14%, with predictors including age >27 years, atrioventricular valve regurgitation, lack of arrhythmia surgery, and male sex.
- Overall survival at 10 years was 67%.
- 84% of patients achieved New York Heart Association class I or II post-conversion.
Conclusions:
- Careful patient selection is crucial for successful Fontan conversion.
- Concomitant arrhythmia surgery may improve survival outcomes.
- Older age and atrioventricular valve regurgitation are associated with increased risk, and cardiac transplantation should be considered.
Background:
Patients with atriopulmonary Fontan tend to undergo conversion to total cavopulmonary connections secondary to arrhythmias or poor flow dynamics. However, the ideal candidate is unknown.
Methods:
Between December 1994 and May 2011, 70 patients (40 males [57%]) underwent Fontan conversion. Median age was 23 years (range, 4 to 46 years). Excluded were 1.5 ventricle conversions. The most common diagnoses included tricuspid atresia in 34 patients (49%) and double-inlet left ventricle in 16 (23%). Atrial tachyarrhythmia was present in 62 patients (89%), 41 (59%) had atrioventricular valve (AVV) regurgitation, and 32 (46%) were in New York Heart Association class III or IV. Atriopulmonary Fontan was the original connection in 58 patients (83%), whereas the Björk modification was performed in 8 (11%).
Results:
Fontan was performed with an intraatrial conduit in 41 patients, an extracardiac conduit in 18, and a lateral tunnel in 11. Forty-nine patients (70%) underwent concomitant arrhythmia operations. Early death occurred in 10 patients (14%). Multivariate analysis revealed age older than 27 years (p = 0.009), AVV regurgitation (p = 0.016), lack of arrhythmia operation (p = 0.04), and male sex (p = 0.02) were predictors of perioperative death. Mean follow-up was 5 years (maximum, 17 years). Overall survival at 1, 5, and 10 years was 81%, 70%, and 67%, respectively, and 84% of patients were in New York Heart Association class I or II.
Conclusions:
Proper selection of Fontan conversion candidates is critical. Concomitant arrhythmia operations may be associated with improved survival. Older age and AVV regurgitation increase the risk of poor outcome, and cardiac transplantation may be a better option.
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