Unsatisfactory Early and Late Outcomes After Fontan Surgery Delayed to Adolescence and Adulthood (original) (raw)
2015, Seminars in Thoracic and Cardiovascular Surgery
Background-The ideal age to perform the Fontan procedure is still unknown. The aim of this study is to determine outcomes after Fontan surgery delayed to adolescence and adulthood in Australia and New Zealand. Methods-Patients who had undergone a Fontan procedure at age 15 or over were identified in the 1133 patients registered in the Australia and New Zealand Fontan Registry until December 2012. A total of 45 patients underwent the following Fontan procedure at a median age of 18.3 years (16-21 years): 24 atrio-pulmonary connections, 10 lateral tunnel and 11 extra-cardiac conduits. ͵ Results-Hospital mortality was 13% (6/45). After a mean follow-up of 15.5 ± 9 years there were 8 late deaths. Survival after 10, 20 and 25 years was 79% (95%CI: 64-89), 70% (95%CI: 51-83) and 70% (95%CI: 51-83) respectively. Freedom from Fontan failure (death, heart transplantation, Fontan takedown, protein-losing enteropathy and poor functional status) after 10 and 20 years was 63% (95%CI: 47-76), and 35% (95%CI: 19-52) respectively. Patients with single left ventricle had a lower risk of failure (HR, 0.25; 95% CI, 0.10-0.59; p=0.002). Twenty-nine patients were noted to develop arrhythmias after a median 0.1 years (0-9.3 years) and 10 required a permanent pacemaker. Freedom from all adverse events at 10 years was 30% (95%CI: 16-45). Conclusions-Outcomes of the Fontan procedure in adolescents and adults are poor with disproportionately high hospital mortality and late adverse events. The Fontan procedure should not be delayed to adolescence and adulthood but should be performed electively in childhood. Central Message Mortality and failure is high when the Fontan is performed after the age of 15. Fontan surgery should not be delayed after adolescence. Perspective Statement The Fontan circulation is still doomed to fail, and some believe that waiting as late as possible to perform the procedure is beneficial. In a retrospective review of 45 patients operated after the age of 15, we demonstrated that hospital mortality and rate of failure were much higher than expected. We therefore suspect that Fontan surgery should not be delayed to adolescence.
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