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Tricuspid atresia and univentricular heart after the Fontan procedure
1Department of Medicine, Mayo Medical School, Rochester, Minnesota.
Insights
Careful patient selection is crucial for the Fontan operation. Alternative treatments like cavopulmonary anastomoses or cardiac transplantation should be considered for high-risk individuals undergoing Fontan procedures.
Area of Science:
- Cardiology
- Pediatric Cardiac Surgery
Background:
- The Fontan operation is a palliative procedure for complex congenital heart disease.
- Careful patient selection is critical for optimal outcomes.
- Long-term complications remain a significant concern despite improved operative risk.
Purpose of the Study:
- To review patient selection criteria for the Fontan operation.
- To discuss alternative treatment options for high-risk patients.
- To emphasize the importance of long-term follow-up and management of complications.
Main Methods:
- Review of existing literature and clinical guidelines.
- Analysis of patient selection criteria (e.g., Choussat et al.).
- Discussion of current and alternative surgical and medical management strategies.
Main Results:
- Optimal results with the Fontan operation are achieved in carefully selected patients meeting specific criteria.
- Cavopulmonary anastomoses and cardiac transplantation are viable alternatives for high-risk candidates.
- Long-term follow-up is essential for monitoring ventricular function, anastomotic sites, and managing arrhythmias and protein levels.
Conclusions:
- The Fontan operation, while improved, remains a palliative procedure.
- Rigorous patient selection and vigilant long-term management are paramount.
- Further research is needed on the impact of early intervention on long-term ventricular function.
Abstract:
Patients undergoing the Fontan operation must be selected carefully. The best results are obtained in those who fulfill the criteria of Choussat et al. Other treatment options are now available. Patients known to be at high risk for the Fontan procedure should be considered for cavopulmonary anastomoses or cardiac transplantation. It is unknown whether performing the Fontan operation at an earlier age will help prevent the long-term problems with ventricular dysfunction. Long-term follow-up of all patients following the Fontan procedure is mandatory with noninvasive assessment of ventricular function and the anastomotic site. Arrhythmias should be managed aggressively with prompt restoration of sinus rhythm, when possible, ideally with antiarrhythmic agents with little or no negative inotropic action. Periodic assessment of serum proteins should be performed. Although the operative risk of the Fontan operation has continued to improve over the last few years, and in one series has been as low as 8%, long-term complications continue and reinforce the concept of the Fontan operation being a palliative rather than a curative procedure.