Insertion of the total artificial heart in the Fontan circulation

Though the Fontan circulation provides long-term palliation for patients with univentricular hearts, failure of the circulation may ensue, leaving heart transplantation as the only definitive treatment. For Fontan patients awaiting transplant, both "right-sided" and "left-sided" symptoms may be present and severe, hence, biventricular mechanical circulatory support may be indicated. This can be provided by implantation of the total artificial heart (TAH), a procedure which is performed slightly differently than in patients with biventricular hearts. In this article, the unique aspects of implantation of this device in a patient with a Fontan operation are reviewed, with specific attention to the most commonly encountered anatomic variants of importance to the implanting surgeon.