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Ann Thorac Surg 2004;77:1334-1340
© 2004 The Society of Thoracic Surgeons

Original article: cardiovascular

Improved early results with the Fontan operation in adults with functional single ventricle

Antonio R. Mott, MDa*, Timothy F. Feltes, MDa, E. Dean McKenzie, MDb, Dean B. Andropoulos, MDc, Louis I. Bezold, MDa, Arnold L. Fenrich, MDa, Shannon L. Bedford, BSNa, Howaida El-Said, MD, PhDa, Stephen A. Stayer, MDc, Charles D. Fraser, Jr, MDb

a Pediatrics–Section of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
b Surgery–Division of Congenital Heart Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
c Anesthesiology–Section of Pediatric Cardiovascular Anesthesia, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA

Accepted for publication October 2, 2003.

* Address reprint requests to Dr Mott, Section of Pediatric Cardiology, Texas Children's Hospital, 6621 Fannin, MC# 19345C, Houston, TX 77030, USA
e-mail: amott{at}bcm.tmc.edu


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
BACKGROUND: A growing number of adults with functional single ventricles are presenting as candidates for first-time and redo-Fontan operations. This study describes the clinical presentation and early operative results of adults who have undergone Fontan modifications.

METHODS: Between July 1995 and April 2003, 23 patients (>18 years old) had Fontan operations. We retrospectively reviewed their perioperative courses.

RESULTS: Twenty-three Fontan operations (first-time [n = 8] and redo [n = 15]) were performed with no early or late deaths. No patient has required reoperation. One patient has been listed for orthotopic heart transplantation. The overall mean age is 23 years (18 to 41 years); mean follow-up, 30 months; median postoperative hospital stay, 8 days (4 to 34 days); and median duration of chest tube drainage, 4 days (2 to 12 days). The postoperative New York Heart Association (NYHA) functional class was improved in 22 of 23 patients. Eight first-time Fontan operations (7 of 8 nonfenestrated) were performed; lateral tunnel (n = 7) and extracardiac conduit (n = 1). Two patients had preoperative arrhythmias. New onset arrhythmias (ventricular tachycardia and sinus node dysfunction), requiring treatment, occurred in two patients. Fifteen redo-Fontan operations (all nonfenestrated) were performed; lateral tunnel (n = 5) and extracardiac conduit (n = 10). Fifteen patients had preoperative arrhythmias, thirteen of which had intraatrial reentry tachycardia (IART) and required antiarrhythmic medications. Concomitant intraoperative radiofrequency ablation (RFA) (n = 11) and cryoablation (n = 1) procedures were performed. In the immediate postoperative period, there was IART recurrence in five patients (post-RFA [n = 4] and postcryoablation [n = 1]). At latest follow-up, no patient is being treated with antiarrhythmic medications. Two patients had new onset atrial arrhythmias that required treatment.

CONCLUSIONS: The Fontan operation can be performed in adults with minimal morbidity and improved NYHA functional class. New onset arrhythmias requiring treatment are sources of perioperative morbidity. Complete arrhythmia resolution of the preoperative arrhythmia may not be achieved in the immediate postoperative period in redo-Fontan patients. However, modification (intraoperative radiofrequency ablation-right atrial debulking) of the atrial tachycardia circuits in the redo-Fontan patients can result in complete resolution of preoperative atrial tachyarrhythmias at early follow-up.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
In the United States alone, there are over one million adults with corrected, palliated, or uncorrected congenital heart disease, and this cohort grows at an annual rate of 5% [1]. An increasing number of these adults have congenital heart defects with a functional single ventricle. Although initially described as a surgical treatment for tricuspid valve atresia [2], modifications of the original Fontan operation are currently being used to treat most other forms of congenital heart defects with a functional single ventricle.

Since the mid to late 1990s, the reported operative mortality risk after the Fontan operation has decreased to less than 5% [3–6]. Several management strategies have been incorporated in order to achieve the improved mortality: universal risk factors or "guidelines" that have resulted in better patient selection; a "staged" approach to the Fontan operation with an interim superior cavopulmonary connection; and modification of the surgical technique to utilize a lateral atrial tunnel with a fenestration. However, prolonged pleural effusions and arrhythmias continue to be sources of postoperative morbidity and prolonged hospital stays [7–9].

Unlike the management of children with a functional single ventricle, the management guidelines have yet to be established for the adult who is a candidate for the Fontan operation. Adults with functional single ventricle usually present the following: (1) as having a "failed" Fontan (chronic arrhythmias, protein losing enteropathy, pleural effusions, ventricular dysfunction, limited exercise capacity); (2) after long-term surgical palliation; or (3) as uncorrected. The purpose of this report is to describe the clinical presentation and early perioperative course in adults who have undergone modifications of the Fontan operation at our institution.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
An initial review of our clinical database was conducted to identify all patients greater than 18 years old who had undergone modifications of the Fontan operation between July 1995 and April 2003. Our research protocol was approved by the Affiliates Review Board for Human Subject Research.

Data collected included demographic data (age at surgery, cardiac diagnosis, surgical date, and cardiac operation). Preoperative echocardiographic and catheterization data were reviewed. Other data included total hospital length of stay, postoperative hospital length of stay, total days in the cardiac intensive care unit, duration of mechanical ventilation, and outcome. Overall mortality was defined as death occurring from the time of surgery to the most recent follow-up. Early postoperative death was defined as that occurring in hospital or less than 30 days following surgery.

Complications reviewed included postoperative issues such as "prolonged" pleural effusions (in-dwelling pleural catheter >7 days or readmission for pleural effusions), pericardial effusions, significant arrhythmias (arrhythmias requiring treatment), neurologic sequelae, postoperative bleeding requiring mediastinal-thoracic exploration, and thromboembolic events.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
Twenty-three patients underwent Fontan operations: first time (n = 8) and redo-Fontan (n = 15). The mean age was 23 years (18 to 41) and the mean follow-up is 30 months. There were no early or late operative deaths. No patient has required reoperation. One patient has been listed for orthotopic heart transplantation (OHT).

First-time Fontan operation
Eight patients underwent first-time operations: lateral tunnel (n = 7) and extracardiac conduit (n = 1). The indications for surgery included cyanosis (n = 8), decreased exercise tolerance (n = 8), and intractable tachyarrhythmia (n = 1). One patient had a fenestration of the lateral tunnel and this patient also sustained a cerebral vascular accident with a left hemiparesis, which is resolving. The mean cardiopulmonary bypass time was 221 (± 92) minutes, mean age was 23 years (18 to 41 years), and mean follow-up is 43 months.

The underlying cardiac diagnoses were L-transposition of the great arteries-straddling atrioventricular valve (n = 2), double inlet left ventricle-transposition of the great arteries-pulmonary valve stenosis (n = 2), complete atrioventricular canal defect – right ventricular dominant (n = 2), tricuspid atresia-pulmonary atresia (n = 1), and double outlet right ventricle-transposed great arteries (n = 1). Prior operations included: aortopulmonary shunt (n = 6), pulmonary artery band (n = 4), and atrial septectomy (n = 1).

Ten secondary operations were performed, which included pulmonary arterioplasty (n = 5), atrial septectomy (n = 2), aortovalvuloplasty (n = 1), and tricuspid valvuloplasty/annuloplasty (n = 2). Other details of the preoperative and perioperative courses are described in Table 1.
Echocardiographic Data
Parameter None Mild Moderate

Ventricular systolic dysfunction 6 0 2
Atrioventricular valve regurgitation 0 5 3

Perioperative Course
Parameters Median Range

Duration of mechanical ventilation (hours) 8 3–230
Duration of chest tube drainage (days) 4 3–12
Cardiac ICU stay (days) 2 1–12
Total postoperative hospital stay (days) 6 5–14
Saturation in room air (%) 95 90–96

ICU = intensive care unit..


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  		Table 1. First-Time Fontan Group (n = 8)

 
One patient with advanced second-degree atrioventricular block before surgery underwent placement of an epicardial pacemaker. One patient with intraatrial reentry tachycardia (IART) underwent concomitant radiofrequency ablation (RFA), had late recurrence of the arrhythmia, and required epicardial pacemaker placement. New onset arrhythmias occurred in two patients in the early postoperative period. One patient had ventricular tachycardia (VT), was treated with propranolol, and has not had recurrence of the VT on follow-up. The other patient was diagnosed with sinus node dysfunction (SND) that required placement of an epicardial pacemaker. Three years after surgery, one patient has been diagnosed with IART. A summary of the arrhythmias and treatment is in Table 2.


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  		Table 2. Summary of Arrhythmias

 
Two patients met criteria for prolonged chest tube drainage: chest tube removal on postoperative day 12 in one patient and one patient requiring readmission with a pleural effusion that required placement of a pleural catheter, which was removed after 3 days. Two patients were diagnosed with pericardial effusions, which resolved without the need for invasive therapy. Seven of eight patients had an improved postoperative New York Heart Association (NYHA) functional class. Figure 1 describes the preoperative and postoperative NYHA functional class.



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  		Fig 1. First-time Fontan operation preoperative (PRE) and postoperative (POST) New York Heart Association functional class.

 
Redo-Fontan operation
Fifteen patients underwent redo-Fontan operations: lateral tunnel (n = 5) and extracardiac conduit (n = 10). The indications for surgery included decreased exercise tolerance (n = 15) and refractory tachyarrhythmia (n = 13). All Fontan modifications were nonfenestrated. The mean total cardiopulmonary bypass time was 190 (± 21.3) minutes and the mean aortic cross time 70 (± 29.4) minutes. The mean age was 23 years (18 to 34 years), mean follow-up is 24 months, and mean time from the first Fontan operation to redo-Fontan operation is 158 months (51 to 204 months).

The underlying cardiac diagnoses were tricuspid atresia with or without normally related great arteries (n = 8), double inlet left ventricle/transposed great arteries (TGA) (n = 2), tetralogy of Fallot-mitral valve atresia (n = 1), heterotaxy with complete atrioventricular canal defect (n = 1), ventricular inversion with L-TGA (n = 1), double outlet right ventricle-mitral valve atresia (n = 1), and pulmonary atresia-intact ventricular septum (n = 1).

Each patient presented with decreased exercise tolerance. Two patients had undergone evaluation for OHT before the redo-Fontan operation. In addition to their first Fontan modification, eight patients had undergone previous placement of an aortopulmonary shunt and atrial septectomy (n = 2).

At the time of surgery, there were 27 secondary operative procedures performed, which included epicardial pacemaker placement (n = 13), right atrial debulking in patients with previous atriopulmonary Fontans (n = 12), radiofrequency ablation (n = 11), and implantable cardioverter defibrillator placement (n = 1). Other details of the preoperative and perioperative courses are described in Table 3.


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  		Table 3. Redo-Fontan Group (n = 15)

 
All patients had preoperative arrhythmias, which included IART (n = 10), SND (n = 2), IART-SND (n = 1), IART-VT (n = 1), and IART-complete atrioventricular block (n = 1). The 13 patients with IART required antiarrhythmic treatment before operation. Concomitant intraoperative radiofrequency ablation (n = 11) and cryoablation (n = 1) were performed. One patient underwent surgical ablation of the right atrium. In the early postoperative period, five patients had arrhythmia recurrence and required treatment with antiarrhythmic medications. There are no patients being treated with antiarrhythmic medications at last follow-up.

Two patients were diagnosed with new onset atrial tachycardia in the early postoperative period; each is well controlled with ß-blocker therapy. A summary of the perioperative arrhythmias and treatment is in Table 2. Each patient had improved NYHA functional classes. Figure 2 describes the preoperative and postoperative NYHA functional class.



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  		Fig 2. Redo-Fontan operation preoperative (PRE) and postoperative (POST) New York Heart Association functional class.

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
Fontan and Baudet's classic Fontan operation and its subsequent modifications have dramatically altered the lives of children and adults with functional single ventricle [3, 5, 6, 10, 11]. For the adult with a "failed" Fontan operation, orthotopic heart transplantation is a surgical alternative [12, 13]. Nonetheless, acceptable morbidity and mortality have been achieved in adults who have undergone first-time and redo-Fontan operations [6, 10, 11, 13–16].

In this study, we report the early operative results in 23 adult patients who have undergone the Fontan operation at our institution. Our overall survival at early follow-up compares favorably with reported studies [6, 13, 15, 16]. An improved postoperative NYHA functional class was achieved in the majority of patients despite some having decreased cardiac indices and elevated ventricular end-diastolic pressures. In those who underwent first-time Fontan operation, improved functional class is possibly secondary to the decreased ventricular volume load. In the redo-Fontan patients, we theorize that obviating coronary sinus hypertension by allowing it to drain into the lower pressure pulmonary venous atrium allows for improved myocardial oxygen delivery and myocardial systolic function.

Adult patients present for the Fontan operation with very unique anatomic and hemodynamic profiles such that the preoperative, intraoperative, and perioperative management strategies must be individualized. Some patients in our population presented with more favorable anatomic and hemodynamic profiles. Still others presented as clinical dilemmas, without any clear-cut favorable anatomic and hemodynamic characteristics or a clear-cut operative strategy. Orthotopic heart transplantation is often considered the best option for this group of patients. Because of this heterogeneity, the proper and decisive timing for operative intervention must be determined, albeit in most cases, nonelective.

Certain aspects of our operative and postoperative strategies warrant discussion. In our series, the Fontan with an extracardiac conduit is used more commonly in the redo-operations, but not exclusively. A Fontan with a lateral tunnel is preferred and is performed in the first-time Fontan operation if the anatomy is favorable. However, in the presence of an anatomic substrate that includes complex systemic or pulmonary venous anatomy, a Fontan with an extracardiac conduit is performed.

The Fontan fenestration was rarely used in our cohort of adults. Fontan fenestration has been shown to decrease early perioperative morbidity in the form of prolonged pleural effusions and increased hospital stay, although the long-term advantages are not known [17]. One patient with preoperative moderate atrioventricular valve regurgitation, moderate ventricular systolic dysfunction, and increased pulmonary vascular resistance had a Fontan modification that incorporated a fenestration. We incorporate the Fontan fenestration in selected younger patients but have tried to avoid the fenestration in adults, secondary to the deleterious effects of acute cyanosis. Also, some of our patients have had previous neurologic insults.

The median durations of chest tube drainage and postoperative hospital stay in our series were low, which compares favorably with adult series in which a Fontan fenestration was not used [6, 13] and with those studies in which a fenestration was used more liberally [10, 14, 15].

Another significant source for perioperative morbidity and mortality is the recurrence of atrial tachyarrhythmias. The indication for redo-Fontan surgery in many of our patients, as in other studies, was refractory IART, with its resultant negative effects on the Fontan circulation [13–16, 18, 19]. While centers report excellent operative and hemodynamic results in children and adults who undergo redo-Fontan surgery, the persistence of preoperative arrhythmias and the occurrence of new onset arrhythmias continue to be sources of postoperative morbidity [14, 15, 20–22].

In our series, 13 of 15 patients presented for redo-Fontan operation with IART and were being treated with oral antiarrhythmic medications. Although complete resolution of the preoperative arrhythmia may not be achieved in the early postoperative period (5 of 13 patients had arrhythmia recurrence in the early postoperative period), perhaps modifications of the tachycardia circuits with concomitant intraoperative radiofrequency ablation (as previously described by and similar to Cox and colleagues [23]) and right atrial debulking in patients with previous atriopulmonary connections have resulted in complete resolution of the IART at last follow-up. A right atrial RFA procedure is preferred in the patient with atrial flutter or intraatrial reentry tachycardia. The RFA lesions are placed between the (1) tricuspid valve and coronary sinus (2), the fossa ovalis and the superior vena cava atriotomy, and (3) the fossa ovalis and the inferior vena cava.

Our results also compare favorably with those of Mavroudis and colleagues [13] who, in a larger cohort of children and adults, reported success with antiarrhythmic surgery concomitant with extensive right-sided and left-sided atrial modification in those patients presenting with failed Fontan circulations. They noted a low incidence of recurrent arrhythmias.

Conclusion
In adult patients presenting for the Fontan operation a comprehensive preoperative management strategy, which includes good patient selection and timely and decisive surgical intervention, can result in improved early outcome with minimal morbidity and improved functional capacity. Complete resolution of the preoperative arrhythmia may not be achieved in the immediate postoperative period in the redo-Fontan patients. However, modifications of the tachycardia circuits with atrial ablation and atrial debulking can result in complete resolution of refractory atrial tachyarrhythmias at early follow-up. New-onset arrhythmias continue to be a source of perioperative morbidity.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. Brickner M.E., Hillis L.D., Lange R.A. Congenital heart disease in adults. N Engl J Med 2000;342:256-263.[Free Full Text]
  2. Fontan F., Baudet E. Surgical repair of tricuspid atresia. Thorax 1971;26:240-248.[Abstract/Free Full Text]
  3. Masuda M., Kado H., Shiokawa Y., et al. Clinical results of the staged Fontan procedure in high-risk children. Ann Thorac Surg 1998;65:1721-1725.[Abstract/Free Full Text]
  4. Mosca R.S., Kulik T.J., Goldberg C.S., et al. Early results of the Fontan procedure in one hundred consecutive patients with hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 2000;119:1110-1118.[Abstract/Free Full Text]
  5. Mott A.R., Spray T.L., Gaynor J.W., et al. Improved early results with cavopulmonary connections. Cardiol Young 2001;11:3-11.[Medline]
  6. Mair D.D., Puga F.J., Danielson G.K. The Fontan operation procedure for tricuspid atresia: early and late results of a 25 year experience with 216 patients. J Am Coll Cardiol 2001;237:933-939.
  7. Cetta F., Feldt R.H., O'Leary P.W., et al. Improved early morbidity and mortality after Fontan operation: the Mayo Clinic experience, 1987 to 1992. J Am Coll Cardiol 1996;28:480-486.[Abstract]
  8. Kaulitz R., Ziemer G., Luhmer I., Kallfeiz H. Modified Fontan operation in functionally univentricular hearts: preoperative risk factors and intermediate results. J Thorac Cardiovasc Surg 1996;112:658-664.[Abstract/Free Full Text]
  9. Durongpisitkul K., Porter C.J., Cetta F., et al. Predictors of early- and late-onset supraventricular tachyarrythmias after Fontan operation. Circulation 1998;98:1099-1107.[Abstract/Free Full Text]
  10. Gates R.N., Laks H., Drinkwater D.C., et al. The Fontan procedure in adults. Ann Thorac Surg 1997;63:1085-1090.[Abstract/Free Full Text]
  11. Humes R.A., Mair D.D., Porter C.J., Puga F.J., Schaff H.V., Danielson G.K. Results of the modified Fontan operation in adults. Am J Cardiol 1988;1:602-604.
  12. Fullerton D.A., Campbell D.N., Jones S.D., et al. Heart transplantation in children and young adults: early and intermediate-term results. Ann Thorac Surg 1995;59:805-812.
  13. Mavroudis C., Backer C.L., Deal B.J., Johnsrude C., Strasburger J. Total cavopulmonary conversion and maze procedure for patients with failure of the Fontan operation. J Thorac Cardiovasc Surg 2001;122:863-871.[Abstract/Free Full Text]
  14. Kreutzer J., Keane J.K., Lock J.E., et al. Conversion of modified Fontan procedure to lateral atrial tunnel cavopulmonary connection. J Thorac Cardiovasc Surg 1996;111:1169-1176.[Abstract/Free Full Text]
  15. McElhinney D.B., Reddy V.M., Moore P., Hanley F.L. Revision of previous Fontan connections to extracardiac or intraatrial conduit cavopulmonary anastomosis. Ann Thorac Surg 1996;62:1276-1283.[Abstract/Free Full Text]
  16. Marcelletti C.F., Hanley F.L., Mavroudis C., et al. Revision of previous Fontan connections to total extracardiac cavopulmonary anastomosis: a multicenter experience. J Thorac Cardiovasc Surg 2000;119:340-346.[Abstract/Free Full Text]
  17. Bridges N.D., Mayer J.E., Lock J.E., et al. Effect of baffle fenestration on outcome of the modified Fontan operation. Circulation 1992;86:1762-1769.[Abstract/Free Full Text]
  18. Gentles TL, Mayer JE, Gauvreau, et al. Fontan operation in five hundred consecutive children: factors influencing early and late outcome. J Thorac Cardiovasc Surg 1997;114:376-91
  19. Fishberger S.B., Wernovsky G., Gentles T.L., et al. Factors that influence the development of atrial flutter after the Fontan operation. J Thorac Cardiovasc Surg 1997;113:80-86.[Abstract/Free Full Text]
  20. Kao J.M., Alejos J.C., Grant P.W., Williams R.G., Shannon K.M., Laks H. Conversion of atriopulmonary to cavopulmonary anastomosis in management of arrhythmias atrial thrombi. Ann Thorac Surg 1994;58:1510-1514.[Abstract]
  21. Vitullo D.A., DeLeon S.Y., Berry T.E., et al. Clinical improvement after revision in Fontan patients. Ann Thorac Surg 1996;61:1797-1804.[Abstract/Free Full Text]
  22. Fenrich A.L., Kertesz N.J., Fraser C.D., McKenzie E.D., Friedman R.A. Intraoperative radiofrequency ablation as an adjunct to treatment of intraatrial reentry tachycardia. PACE 2001;24:588.
  23. Cox J.L., Boineau J.P., Schuessler R.B., Jaquiss R.D.B., Lappis D.G. Modification of the maze procedure for atrial flutter and atrial fibrillation. J Thorac Cardiovasc Surg 1995;110:473-484.[Abstract/Free Full Text]



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