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Background—To determine whether patients undergoing the lateral tunnel and extracardiac conduit modifications of the
Fontan procedure have better outcomes than patients undergoing a classical atriopulmonary connection.
Methods and Results—Between 1980 and 2000, 305 consecutive patients underwent a Fontan procedure at our institution.
There were 10 hospital deaths (mortality: 3%) with no death after 1990. Independent risk factors for mortality were
preoperative elevated pulmonary artery pressures (P⫽0.002) and common atrioventricular valve (P⫽0.04). Fontan was
taken down during hospital stay in 7 patients. A mean of 12⫾6 years of follow-up was obtained in the 257 nonforeign
Fontan survivors. Completeness of concurrent follow-up was 96%. Twenty-year survival was 84% (95% CI: 79 to 89%).
Recent techniques improved late survival. The 15-year survival after atriopulmonary connection was 81% (95% CI: 73%
to 87%) versus 94% (95% CI: 79% to 98%) for lateral tunnel (P⫽0.004). Nine pts required heart transplantation (8
atriopulmonary connection, 1 lateral tunnel). Undergoing a Fontan modification independently predicted decreased
occurrence of arrhythmia, and 15-year freedom from SVT was 61% (95% CI: 51% to 70%) for atriopulmonary
connection versus 87% (95% CI: 76% to 93%) for lateral tunnel (P⫽0.02). Freedom from Fontan failure (death,
take-down, transplantation, or NYHA class III-IV) was 70% (95% CI: 58% to 79%) at 20 years. After extra-cardiac
conduits, no death, SVT, or failure was observed.
Conclusions—The Fontan procedure remains a palliation, but outcomes of patients have improved. Better patient selection
minimizes hospital mortality. Patients with lateral tunnel and extracardiac conduit modifications experience less
arrhythmia and are likely to have failure of their Fontan circulation postponed. (Circulation. 2007;116[suppl I]:I-157–
I-164.)
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From the Departments of Cardiac Surgery (Y.d’U., A.J.I., A.D.C., C.P.B.) and Cardiology (D.J.P.), Royal Children’s Hospital and the Department of
Pediatrics, the University of Melbourne; Department of Cardiology (L.G.), Royal Melbourne Hospital; Department of Cardiology (J.M.R.), Princess
Margaret Hospital for Children, Perth; Department of Cardiology (G.R.W.), Adelaide Women’s and Children’s Hospital, Adelaide; Australia and New
Zealand Children’s Heart Research Center, Australia.
Presented at the American Heart Association Scientific Sessions, Chicago, Ill, November 12–15, 2006.
Correspondence to Yves d’Udekem, Department of Cardiac Surgery, Royal Children’s Hopital, Flemington Road, Parkville, Melbourne 3052, Victoria
Australia. E-mail yves.dudekem@rch.org.au
© 2007 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.106.676445
I-157
I-158 Circulation September 11, 2007
Figure 1. Fontan surgical techniques: Classical atriopulmonary connection (A), Lateral tunnel (B), and extracardiac conduit (C).
mias, heart failure, and progressive rise of their pulmonary From 1980 to 1995, 152 patients (50%) underwent a classical
vascular resistances.5–9 Conversion of the atriopulmonary atriopulmonary connection. In 31 patients, isolation of the right
atrium was achieved by the direct closure of the ASD and the
connection or the lateral tunnel technique to the extracardiac
tricuspid valve, and in 121, patches of Gore-Tex (WL Gore &
technique has been successful in treating failing Fontan Associates, Inc) were used. From 1988 to 1999, 105 patients (34%)
patients, but the indication of this new procedure are still had a lateral tunnel modification. In 48 patients (16%) from 1998 to
under investigation.10,11 Because it is still unclear whether the 2000, the Fontan procedure consisted in the implantation of an
technical modifications brought to the initial Fontan opera- extracardiac conduit. The conduit consisted of a Gore-Tex prosthetic
tube in 42 patients and an aortic homograft in 6. Fenestration
tion translated into long-term clinical benefits, we decided to
between the systemic venous blood circuit and the pulmonary venous
review our clinical experience with these three techniques. atrium was performed according to the surgeon preference, only in
patients undergoing lateral tunnel technique and extracardiac
Patients and Methods conduit.
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common atrioventricular valve were independent predictors tunnel (P⫽0.004). During the 10 years of follow-up available
of hospital mortality. Surgical era, previous staging with for the patients undergoing an extra-cardiac conduit, no death
bidirectional Glenn, and fenestration of the Fontan could not occurred. Identified predictors of late mortality are listed in
be tested because there was no mortality after 1990, at the Table 4. Prior staging with bidirectional Glenn improved
time staging and fenestration were implemented. survival (P⫽0.026). Kaplan-Meier curves of late survival
according to the Fontan technique used are displayed in
Long-Term Survival Figure 2.
Thirty-three patients (14 with an atriopulmonary connection,
15 with a lateral tunnel, and 4 with an extracardiac conduit) Reinterventions
who had been referred from foreign countries were excluded Forty-two reoperations were performed in 34 hospital survi-
from the study of the long-term impact of the Fontan vors (24 after an atriopulmonary connection, 8 after lateral
procedure. The total cohort of patients valid for the long-term tunnel, and 2 after extra-cardiac conduit) after a median time
follow-up studies consisted of 257 Australian hospital survi- of 5.7 years (2 to 14 years). Two patients had their Fontan
vors with a Fontan circulation. Six of the 257 were lost to
taken down to a bidirectional Glenn. Six patients had a
follow-up. The completeness of concurrent follow-up (2003–
revision of their Fontan circuit (3 atriopulmonary connections
2006) was 96% for a mean follow-up of 12⫾6 years.
and 3 extracardiac conduits) resulting in 1 death, and 8
Twenty-eight late deaths occurred a median of 7 years (1 to
underwent a conversion of an atriopulmonary connection to
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circulation, 176 (82%) were on warfarin, 18 on aspirin only Late Fontan failure occurred in 42 patients after a median of
(8%), and 21 were not taking any anticoagulation (10%). 8.5 years (2.3 to 15.6 years). There were 25 deaths (22
Thirteen patients had a documented history of clinical throm- atriopulmonary connections, 1 lateral tunnel), 2 Fontan take-
boembolic events. All patients were taking warfarin at the downs (1 atriopulmonary connection, 1 lateral tunnel), 9 heart
time of the event. Eleven of these patients had a classical transplantations (8 atriopulmonary connections, 1 lateral
atriopulmonary connection, 1 a lateral tunnel, and 1 an tunnel), and 6 patients were in NYHA class III or IV (all
extracardiac conduit. Nine patients had clinical evidence of atriopulmonary connections). Thirty-seven patients undergo-
pulmonary embolism, 7 of them being in supraventricular ing failure had an atriopulmonary connection and 5 had a
tachycardia at the time (8 atriopulmonary connections and lateral tunnel technique. Freedom from late Fontan failure
one extra-cardiac conduit). One stroke and 1 transient ische- was 84.6% (95% CI: 78.4 to 89.1%) at 15 years and 69.6%
mic attack occurred during cardiac catheterization at 6 (95% CI: 58 to 78.6%) at 20 years. Predictive risks factors for
months and 15 years postoperatively. One patient had a failure are displayed in Table 7.
transient ischemic attack and the last patient had a renal
infarct. Freedom from thromboembolic events was 96.9% Discussion
(95% CI: 93.7 to 98.5%) at 10 years and 94.3% (95% CI: 89.2 Despite its widespread application, there have been increas-
to 97.1%) at 15 years. Risks factors predictive of thrombo- ing concerns that the Fontan procedure is merely a palliative
embolic events have been displayed in Table 5. operation. Many in the medical community believe that most
Two bleeding events were reported. One patient had a of these patients are doomed to death or heart transplantation
thigh compartment syndrome and one a subdural hemorrhage. in the decades that will follow this procedure. Since its
original description, the Fontan operation has undergone the most potent predictor of late Fontan failure, most likely
several modifications aimed at improving streaming of the because of the tendency of these valves to become regurgi-
systemic venous blood to the lungs, namely the lateral tunnel tant.6 Patients who underwent pulmonary artery reconstruc-
and the extracardiac conduit. So far, the long-term benefits of tion, who presumably possessed a less favorable pulmonary
these modifications have not been clearly ascertained. The vascular bed, had a greater chance of long-term failure of
present study now shows that the experience gained over time their Fontan. Some of the predictive factors identified were
with the Fontan procedure benefited patients not only in contemporaneous events rather than true predictors. Throm-
terms of short-term survival, but also long-term outcome. bus formation and supraventricular tachycardia are both
Patient selection has clearly varied with time. In the 1980s, correlates of atrial dilatation and it was not surprising that
Fontan procedures were offered to patients with elevated thromboembolic events predicted occurrence of supraventric-
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pulmonary pressures. It is likely that the low hospital mor- ular arrhythmia. Fontan conversion in this initial experience
tality observed after 1990 was related to improved patient was offered to failing patients and accordingly correlated
selection, better adjustment of pulmonary blood flow, and to with occurrence of thromboembolic events.
staging with bidirectional Glenn. Staging might have been There were relatively few thromboembolic events in this
beneficial because of the well-documented relief of ventric- series of patients. Apart from very few exceptions, it has been
ular volume loading, but also might have added a further our policy to systematically anticoagulate patients with war-
opportunity for careful patient selection.4 Because hospital farin for life, and it is therefore difficult for us to evaluate its
mortality was eliminated in the second part of the study, at the benefits. This policy did not give absolute protection to our
time when staging with bidirectional Glenn and surgical patients, as most of those who experienced thromboembolic
fenestration were implemented, the impact of these measures events were anticoagulated at the time of the event.
could not be evaluated due to a lack of end points. The most striking point arising from the follow-up of these
Two patients had their Fontan taken down at the operation, patients is the improvement in their long-term outcome,
7 during the hospital stay, and 2 in the first years following its despite the fact that the Fontan procedure seems to remain a
completion. It is possible that this aggressive approach to palliative operation. The previously quoted 20-year survival
patients showing signs of failure spared us some mortality. of Fontan patients with atriopulmonary connections was
The morphological features determining patients’ poorer 65%.7 The 85% survival at 20 years achieved in our operative
outcomes are similar to those identified previously. Patients cohort heralds a marked improvement, especially in view of
with a common atrioventricular valve were more likely to die the inevitable improvement of results in the forthcoming
after the procedure. In Gentles et al’s study, this feature was years. The 15 year-survival of the patients having a lateral
tunnel was 94%. Although there was a gradual increase in the
rate of failure of the atriopulmonary connection Fontan after
10 years, this trend was not yet observed in the time frame of
this study in the lateral tunnel Fontan.
The occurrence of supraventricular tachycardia as a con-
sequence of right atrial dilatation was the predominant reason
that motivated the modification of the original Fontan tech-
nique into the lateral tunnel technique. Eighteen years after its
description by de Leval, this technical modification has
clearly brought benefits to patients in terms of protection
Figure 3. Freedom from SVT by Fontan techniques. from supraventricular tachyarrhytmia. If one believes that
I-164 Circulation September 11, 2007
practice and care has evolved. The improvement in patient operation: factors influencing late morbidity. J Thorac Cardiovasc Surg.
114:392– 403, 1997; discussion 404 –5.
care may have been multifactorial, and some factors not 6. Gentles TL, Mayer JE, Jr., Gauvreau K, Newburger JW, Lock JE, Kupfer-
strictly related to the surgical procedure may not have been schmid JP, Burnett J, Jonas RA, Castaneda AR, Wernovsky G. Fontan
analyzed. It is likely that the patient population operated at operation in five hundred consecutive patients: factors influencing early
the beginning of this experience differs from today’s practice. and late outcome. J Thorac Cardiovasc Surg. 1997;114:376 –391.
7. Fontan F, Kirklin JW, Fernandez G, Costa F, Naftel DC, Tritto F,
In particular, we are now operating more patients with Blackstone EH. Outcome after a “perfect” Fontan operation. Circulation.
hypoplastic left heart syndrome, and some of the conclusions 1990;81:1520 –1536.
drawn may not apply to all categories of patients. By 8. Driscoll DJ, Offord KP, Feldt RH, Schaff HV, Puga FJ, Danielson GK.
Five- to fifteen-year follow-up after Fontan operation. Circulation. 1992;
definition, this study applies to a very heterogenous group of 85:469 – 496.
patients. It is therefore possible that some parameters that 9. Mitchell MB, Campbell DN, Ivy D, Boucek MM, Sondheimer HM, Pietra
may impact outcomes were not found in sufficient numbers. B, Das BB, Coll JR. Evidence of pulmonary vascular disease after heart
We conclude that the outcomes of patients undergoing transplantation for Fontan circulation failure. J Thorac Cardiovasc Surg.
2004;128:693–702.
Fontan procedures have improved. Better patient selection 10. Morales DL, Dibardino DJ, Braud BE, Fenrich AL, Heinle JS, Vaughn
and management, as improved surgical techniques, have WK, McKenzie ED, Fraser CD, Jr. Salvaging the failing Fontan: lateral
contributed to minimize hospital mortality. Patients with the tunnel versus extracardiac conduit. Ann Thorac Surg. 2005;80:
1445–1451; discussion 1451–2.
lateral tunnel and extracardiac conduit variations of the
11. Backer CL, Deal BJ, Mavroudis C, Franklin WH, Stewart RD. Con-
Fontan experience less arrhythmia and are likely to have the version of the failed Fontan circulation. Cardiol Young. 2006;16(suppl
failure of their Fontan circulation postponed. 1):85–91.