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Surgical options after Fontan failure
Joost P van Melle1, Djoeke Wolff2, Jürgen Hörer3
1Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
Heart (British Cardiac Society)
|April 15, 2016
Summary
Fontan takedown surgery for failing Fontan circulation carries a high early mortality risk. Fontan conversion and heart transplantation (HTX) offer similar survival rates for late Fontan failure.
Area of Science:
- Cardiology
- Congenital Heart Surgery
- Pediatric Cardiology
Background:
- The Fontan procedure is a palliative surgery for single-ventricle congenital heart defects.
- Failing Fontan circulation presents a significant clinical challenge, necessitating further intervention.
- Treatment options include Fontan takedown, Fontan conversion, and heart transplantation (HTX).
Purpose of the Study:
- To compare the surgical outcomes of Fontan takedown, Fontan conversion, and HTX in patients with failing Fontan circulation.
- To evaluate all-cause mortality and the need for re-transplantation as primary endpoints.
Main Methods:
- A retrospective international multicenter study involving 22 European centers.
- Data collected from 225 patients undergoing surgery for failing Fontan circulation.
- Patients were categorized into Fontan takedown (n=38), Fontan conversion (n=137), or HTX (n=50).
Main Results:
- Arrhythmia was the most common indication for surgery (43.6%), with differing indications across groups.
- Fontan takedown was primarily for early failure, while conversion and HTX addressed late failure.
- Early mortality was high for Fontan takedown (26%). Combined mortality/HTX rates were 44.7% for takedown, 26.3% for conversion, and 34.0% for HTX.
- No significant difference in survival was observed between Fontan conversion and HTX (p=0.13).
- Ventricular systolic dysfunction was a key predictor of mortality or re-transplantation in conversion and HTX groups.
- Patients with valveless atriopulmonary connections benefited more from Fontan conversion.
Conclusions:
- Fontan takedown surgery for failing Fontan circulation, especially in the early postoperative phase, is associated with high mortality.
- Fontan conversion and heart transplantation demonstrate comparable long-term survival outcomes for patients with late Fontan failure.
- Ventricular systolic dysfunction is a critical factor influencing outcomes in patients undergoing Fontan conversion or HTX.
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