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24-Year Results of Non-Fenestrated Extracardiac Fontan Including Fontan Conversions

Stephens, E. H.; Talwar, A. A.; Devlin, P. J.; Eltayeb, O.; Mongé, M. C.; Tsao, S.; Backer, C. L.

Ann Thorac Surg. 2020 Aug 17

Abstract

BACKGROUND: There is an active debate regarding the optimal method of Fontan palliation. In light of this, we reviewed our experience with the non-fenestrated extracardiac Fontan including Fontan conversion. METHODS: Retrospective review was performed of all non-fenestrated extracardiac Fontan and Fontan conversion operations at our institution from 12/1994 to 12/31/2018. Standard demographic data were collected, including underlying anatomy, preoperative ventricular and valvular function, operative details, perioperative data, and clinical outcomes. Statistical analysis included comparison between initial extracardiac Fontan patients and Fontan conversions, as well as analysis for risk factors for adverse outcomes. RESULTS: There were 341 patients with an overall operative mortality of 4 patients (1.2%). Of these, 193 (57%) were extracardiac non-fenestrated Fontan completion operations and 148 (43%) were Fontan conversions. Length-of-stay was 11 (6) days with ventilator duration of 28 (26) hours. Six (3%) of the completion Fontan patients required Fontan takedown at a median time of 2.5 days. On multivariable analysis, risk factors associated with adverse events (mortality, Fontan takedown, and/or transplant) included increased cardiopulmonary bypass time, preoperative decreased dominant ventricular function, and length-of-stay. Kaplan Meier curves demonstrated that mild or greater preoperative ventricular dysfunction decreased survival as well as freedom from adverse events for both initial extracardiac Fontan and Fontan conversion patients. CONCLUSIONS: Over the past 24 years our strategy of non-fenestrated extracardiac Fontan has achieved low operative mortality for both initial Fontan and Fontan conversion. There is a steady attrition of Fontan patients to cardiac transplantation, with a key risk factor being preoperative ventricular dysfunction.

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