The mid-term surgical results of Fontan conversion with antiarrhythmia surgery (original) (raw)
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Fontan conversion with arrhythmia surgery☆
European Journal of Cardio-Thoracic Surgery, 2005
Hemodynamic abnormalities and refractory atrial arrhythmias in patients late after the Fontan operation result in significant morbidity and mortality. We reviewed our experience with Fontan conversion and concomitant arrhythmia surgery. Between January 1996 and February 2004, 16 patients underwent Fontan conversion and arrhythmia surgery. Mean age at the initial Fontan operation was 5.1+/-3.5 (range: 2-15) years and mean age at Fontan conversion was 17.0+/-5.8 (range: 6-30). The initial Fontan operations were atriopulmonary connections in 14 patients, extracardiac lateral tunnel in 1, and intracardiac lateral tunnel in 1. The types of arrhythmia included atrial flutter in 10 patients and atrial fibrillation in 3. Fontan conversion operation was performed with intracardiac lateral tunnel in 5 patients and extracardiac conduit in 11. Arrhythmia surgery included isthmus cryoablation in 10 patients and right-sided maze in 3. There has been no mortality. At Fontan conversion operation, 7 patients required permanent pacemaker. All patients have improved to New York Heart Association class I or II. With a mean follow-up of 26.9+/-30.6 (range:1-87) months, 16 patients had sinus rhythm, 2 patients had transient atrial flutter which was well controlled, and 2 patients required permanent pacemaker during follow-up. Fontan conversion with concomitant arrhythmia surgery and permanent pacemaker placement is safe, improves New York Heart Association functional class, and has a low incidence of recurrent arrhythmias. In most patients, concomitant permanent pacemakers are needed.
Surgical Therapy of Arrhythmias in Single‐Ventricle Patients Undergoing Fontan or Fontan Conversion
Journal of Cardiac Surgery, 2009
Background: Arrhythmia is detrimental to Fontan hemodynamics. Clinical outcomes among Fontan patients who underwent antiarrhythmic treatment were retrospectively reviewed. Methods: From January 1996 to January 2007, 182 patients underwent a Fontan procedure, including Fontan conversion. Thirty-nine of the 182 patients showed various arrhythmias pre-or post-Fontan operations, and were treated surgically including Fontan conversion (18 patients) or medically. The authors analyzed the outcomes of arrhythmia treatments retrospectively. Results: Thirty-nine patients (21.4%) showed various arrhythmias, such as atrial flutter, atrial fibrillation, junctional rhythm, sinus node dysfunction, or brady tachyarrhythmia pre-or post-Fontan procedure. Follow-up duration was 13.1 ± 8.7 years (11 months to 325 months). Atrial flutter and fibrillation only developed in 17 patients who received atriopulmonary connection Fontan, and who were treated by Fontan conversion with concomitant procedures such as Cox-maze procedure (two patients), right-side maze and pacemaker implantation (five patients), right atrial isthmus ablation (four patients), right atrial isthmus cryoablation and pacemaker implantation (five patients), and only pacemaker implantation (one patient). The 21 patients who showed arrhythmia at the time of the Fontan procedure underwent the following procedures concomitantly: right atrial isthmus cryoablation with pacemaker implantation (one patient), right atrial isthmus cryoablation (one patient), or pacemaker implantation (nine patients). The remaining 10 patients, who showed junctional rhythm, sinus bradycardia, or intermittent ectopic beats, were managed medically. There were two late mortalities due to protein-losing enteropathy. As a result, 33 patients (89.2%) maintained atrioventricular synchrony, 19 in sinus rhythm and 14 supported by a DDD-type pacemaker. The remaining four patients (10.8%) showed persistent junctional rhythm with a stable hemodynamic status. Conclusions: The various arrhythmias in Fontan patients were well controlled by aggressive surgical management.
Congenital Heart Disease, 2010
To evaluate the incidence of atrial tachy-arrhythmia (AT) recurrence following conversion from right atrial-pulmonary artery (RA-PA) Fontan to total cavopulmonary connection (TCPC) in adults. AT is a recognized sequel of Fontan palliation, especially in RA-PA Fontans, and is associated with significant morbidity. While catheter ablation achieves fairly reliable short-term success with low morbidity, conversion to TCPC with arrhythmia surgery is a highly effective treatment option for the classical Fontan patients with incessant AT. Single center retrospective review. Twenty-seven adults underwent Fontan conversion from RA-PA to TCPC, mostly for AT indications (n = 24). Nine (33%) underwent conversion to a lateral tunnel (LT) and 18 (67%) to an extracardiac (EC) Fontan. Two patients died <30 days post-operatively. Both had liver failure and had been turned down for cardiac/liver transplantation. In-hospital complications occurred in 15/27 patients (55%), including recurrence of AT requiring cardioversion in six patients (22%) and persistent pleural effusions in 4 (15%). Mean follow-up was 4.2 years (range 3 months-14 years). Functional capacity improved from mean New York Heart Association (NYHA) class 1.8 pre-conversion to 1.2 post-conversion (P= 0.008). Twenty-one patients had concomitant arrhythmia surgery (MAZE in 12 patients with IART and Cox-MAZE in nine patients with A-Fib +/- IART). Of these, 3/21 (14%) had AT recurrence >3 months following conversion. Conversion from RA-PA Fontan to TCPC, with arrhythmia surgery, decreases AT recurrence and improves functional capacity. The risk of peri-operative mortality is highest in patients with cirrhosis. AT recurred in 14% of patients.
Device management of arrhythmias after Fontan conversion
The Journal of Thoracic and Cardiovascular Surgery, 2009
Objectives: We assessed our pacemaker strategy, use of antitachycardia therapies, generator longevity, and need for programming changes in patients having Fontan conversion with arrhythmia surgery.
Heart, 2003
Objectives: To assess the early results of conversion from atriopulmonary to total cavopulmonary connection in patients with failing Fontan operation. Design: Early clinical and instrumental evaluation of patients undergoing conversion from atriopulmonary to total cavopulmonary connection from April 1999 to November 2000. Setting: Tertiary referral centre for congenital heart disease. Patients: 11 Fontan patients (mean (SD) age 20.9 (6.7) years) with refractory arrhythmias or ventricular dysfunction. Interventions: Total cavopulmonary connection, intraoperative ablation, and AAIR pacemaker implantation. Main outcome measures: Holter monitoring, transoesophageal atrial stimulation, ergometric test, and myocardial scintigraphy at a mean (SD) follow up of 16.8 (5.6) months. Results: One early postoperative death occurred. During follow up three patients had relapse of atrial tachycardia, controlled by medical treatment, and two were pacemaker dependent. Transoesophageal stimulation did not induce atrial tachycardia in any patient. Ergometric test showed a diminished exercise tolerance in all but one patient. Mean minute ventilation and maximum oxygen consumption were 62% and 40% of their respective predicted values. Myocardial scintigraphy showed reversal of rest or exercise dysfunction in five patients and improved systemic ventricular function in seven. Mean basal ejection fraction increased from 39.4% (95% confidence interval (CI) 32% to 46%) to 46.5% (95% CI 41.7% to 51.2%) and ejection fraction on effort from 42.3% (95% CI 33.9% to 50.7%) to 50.2% (95% CI 44.5% to 55.9%). Conclusions: Our data show that total cavopulmonary connection associated with intraoperative ablation and pacemaker implantation allows for better control of arrhythmias and improves ventricular function in the majority of patients with failing Fontan.
The Annals of Thoracic Surgery, 2003
Arrhythmia operations may be extended to patients with failed ablation procedures or associated structural defects requiring surgical intervention. The purpose of this study is to review our experience with arrhythmia operations in 29 patients who did not have Fontan conversions after the introduction of catheter ablation. Between July 1992 and January 2002, 29 patients had operations for refractory atrial (n = 24) or ventricular (n = 5) arrhythmias. Mechanisms of arrhythmia included atrial reentry (n = 11), atrial fibrillation (n = 5), automatic atrial (n = 3), accessory connections (n = 6), atrioventricular nodal reentry (n = 2), and ventricular tachycardia (n = 5). Median age at operation was 12.3 years (range, 6 days to 45 years). Two patients had structurally normal hearts; the remaining 27 patients underwent concomitant repair of structural heart disease, including atrioventricular valve replacement or repair (n = 8), anatomy-specific repair of Ebstein's anomaly (n = 4), tetralogy of Fallot repair or revision (n = 4), atrial septal defect closure (n = 3), ventricular septal defect repair (n = 2), Mustard takedown with arterial switch (n = 2), initial Fontan (n = 2), right ventricle-to-pulmonary artery conduit revision (n = 2), Norwood procedure (n = 1), 1 ventricular repair for Uhl's anomaly (n = 1), Mustard baffle revision (n = 1), pulmonary valve replacement with aneurysm resection (n = 1), and aortic valve replacement with complex repair (n = 1). No patient developed heart block, and the surgical mortality rate was 7%. One patient died after Mustard takedown and arterial switch operation, and 1 neonate died after repair of severe Ebstein's anomaly. There was one late death after arterial switch conversion at another institution. Recurrent clinical supraventricular tachycardia was present in 2 patients (2 of 27, 7.4%) and 2 patients had new-onset tachycardias with different underlying mechanisms of arrhythmia at late follow-up (median follow-up 47 months). Successful surgical therapy of arrhythmias can be performed safely at the time of repair of complex congenital heart disease or in patients with failed catheter ablation procedures. Early consideration for single-stage therapy of arrhythmia and structural heart disease is indicated.
Intra-atrial reentrant tachycardia in adult patients after Fontan operation
International journal of cardiology, 2015
Atrial tachyarrhythmia is a major late complication in adult Fontan patients. This study examined the clinical features and risk factors of late intra-atrial reentrant tachyarrhythmia (IART) in adult patients after Fontan surgery and the mid-term outcome of Fontan conversion with or without antiarrhythmic surgery in these patients. We conducted a retrospective study on adult patients who were born before 1994 and survived at least 3months after a Fontan operation at Seoul National University Children's Hospital. We followed 160 patients over 20.9±4.1years. Sustained atrial tachycardia was identified in 51 patients, and IART was found in 41, appearing a mean 13.6years after surgery. By the 25year follow-up, 40% had developed IART. The incidence of IART significantly increased over time. Patients with an atriopulmonary connection (APC) (n=65) had significantly longer follow-up duration and higher incidence of IART than patients with a lateral tunnel (n=86) or extracardiac conduit ...