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Arrhythmias and thromboembolic complications after the extracardiac Fontan operation
L K Shirai1, D N Rosenthal, B A Reitz
1Department of Pediatrics, Stanford University, Calif, USA.
Insights
The extracardiac Fontan procedure may reduce tachyarrhythmias after surgery. However, sinus node dysfunction is common, and anticoagulation is recommended indefinitely due to similar thrombotic event rates.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Congenital Heart Disease
Background:
- Late Fontan operation morbidity includes arrhythmias, ventricular failure, and thrombus.
- Extracardiac Fontan (EC-Fontan) avoids atrial manipulation, potentially reducing these complications.
- This study evaluates EC-Fontan outcomes, focusing on thromboembolism and arrhythmias.
Purpose of the Study:
- To assess the incidence of thromboembolism and arrhythmias after the extracardiac Fontan procedure.
- To evaluate the safety and efficacy of the extracardiac Fontan technique.
Main Methods:
- Retrospective review of 16 patients undergoing extracardiac Fontan (July 1993-May 1996).
- Analysis of pre- and post-operative arrhythmias, sinus node function (Holter), and thrombus formation.
- Echocardiographic assessment for conduit obstruction.
Main Results:
- 94% of patients were in sinus rhythm pre-operatively; 44% experienced arrhythmias post-operatively.
- 50% had arrhythmias on ECG, and 44% showed sinus node dysfunction on Holter monitoring.
- Thrombi occurred in 19% of patients; no conduit obstruction or early deaths were observed.
Conclusions:
- The extracardiac Fontan procedure may reduce hemodynamically significant tachyarrhythmias.
- Sinus node dysfunction is prevalent, suggesting other contributing factors.
- Indefinite anticoagulation is a reasonable consideration given similar thrombotic event rates to other Fontan modifications.
Background:
Late morbidity and mortality after the Fontan operation are largely due to atrial arrhythmias, ventricular failure, and thrombus formation. The extracardiac Fontan procedure avoids extensive atrial manipulation and suture lines, theoretically minimizing the impetus for these events. We examined our experience with the extracardiac Fontan operation with particular attention to thromboembolism and arrhythmias.
Methods And Results:
We retrospectively reviewed the medical and surgical records of all 16 patients who underwent an extracardiac Fontan operation between July 1993 and May 1996. Fifteen patients (94%) were in sinus rhythm before the operation. In the immediate postoperative period, seven (44%) had arrhythmias consisting of accelerated junctional rhythm and ectopic atrial rhythm. No associated hemodynamic compromise and no early deaths occurred. Patients were followed up for 3 to 34 months after the Fontan operation. Arrhythmias were detected in eight patients (50%) on surface electrocardiograms, and seven (44%) showed evidence of sinus node dysfunction on 24-hour Holter monitor studies. Thrombi were found in three patients (19%). All patients were asymptomatic, with no evidence of conduit obstruction by echocardiogram.
Conclusions:
The incidence of hemodynamically significant tachyarrhythmias appears to be reduced after the extracardiac Fontan operation. A significant percentage of patients have evidence of sinus node dysfunction, suggesting the presence of other surgical or nonsurgical factors responsible for this finding. Our incidence of thrombotic events is similar to previous reports with other Fontan modifications. It appears to be a reasonable option to maintain these patients on anticoagulation indefinitely.