Elsevier

The Annals of Thoracic Surgery

Volume 84, Issue 5, November 2007, Pages 1457-1466
The Annals of Thoracic Surgery

J. Maxwell Chamberlain memorial paper for congenital heart surgery
111 Fontan Conversions with Arrhythmia Surgery: Surgical Lessons and Outcomes

Presented at the Forty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 29–31, 2007.
https://doi.org/10.1016/j.athoracsur.2007.06.079Get rights and content

Background

The evolving operative strategy and course of 111 consecutive Fontan conversions with arrhythmia surgery and pacemaker therapy were reviewed to identify risk factors for poor outcome.

Methods

Since 1994, 111 patients (mean age 22.5 ± 7.9 years) underwent Fontan conversion with arrhythmia surgery. The series was divided into three time periods: (1) 1994 to 1996 (initial isthmus ablation, n = 9, group I); (2) 1996 to 2003 (early modified right atrial maze and Cox-maze III, n = 51, group II); and (3) 2003 to 2006 (recent modifications of the modified right atrial maze and left atrial Cox-maze III for both atrial fibrillation and left atrial reentry tachycardia, n = 51, group III).

Results

There were one early (0.9%) and six late deaths (5.4%); six patients required cardiac transplantation (5.4%). Two late deaths occurred after transplantation. Renal failure requiring dialysis occurred in four patients (3.6%). Mean hospital stay was 13.7 ± 12.1 days. Mean cross-clamp time was 70.8 ± 41.6 minutes. Four risk factors for death or transplantation were identified: presence of a right or ambiguous ventricle, preoperative protein-losing enteropathy, preoperative moderate-to-severe atrioventricular valve regurgitation, and long (>239 minutes) cardiopulmonary bypass time. In intergroup comparisons (groups I and II versus group III), three trends were noted: increased incidence of concomitant surgical repairs (p = 0.03), older patients (p = 0.01), and increased incidence of left atrial reentry tachycardia and atrial fibrillation (p = 0.04). Late recurrence of atrial tachycardia ensued in 15 of 111 (13.5%); 8 of 51 in group II (15.7%) and 4 of 51 in group III (7.8) (p = 0.3).

Conclusions

Fontan conversion with arrhythmia surgery is safe and efficacious. Based on improved results and evolving surgical techniques, selection criteria can be more clearly defined.

Section snippets

Patients and Methods

This is a retrospective clinical study of 111 consecutive patients who underwent Fontan conversion with arrhythmia surgery between December 1994 and November 2006. This study was approved by the Institutional Review Board of Children’s Memorial Hospital as a retrospective analysis; the need for patient consent was waived.

Results

Table 1, Table 2, Table 3 show the emergence of an increasingly complex patient population. In a comparison of groups I and II versus group III, three trends are apparent: increased incidence of concomitant surgical repairs (p = 0.03); older patients (p = 0.01); and increased incidence of left atrial reentry tachycardia and atrial fibrillation necessitating performance of Cox-maze III operations (p = 0.04). The mean postoperative hospital stay for all patients was 13.7 ± 12.1 days (group I, 8.7

Comment

This clinical review confirms the favorable outcome of Fontan conversion with arrhythmia surgery for patients with tricuspid atresia and atriopulmonary connections published earlier by us [1, 2, 5] and others [7, 14, 15]. Importantly, this series demonstrates the efficacy of this surgery for patients with increasingly complex anatomic lesions, and atrial fibrillation or left atrial tachycardia. In this challenging population, we have demonstrated continued low mortality and excellent arrhythmia

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Winner of the J. Maxwell Chamberlain Memorial Award for Congenital Heart Surgery.

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