Dr van Melle and associates from the European Congenital Heart Surgeons Association (ECHSA) are to be congratulated on their multicenter study on the treatment of failed Fontan patients.1 With the Fontan operation now being 40 years old surgeons are seeing the full spectrum of Fontan circulation failures.2 Strategies (and outcomes) for treating these patients are critically important and the review from the ECHSA is very timely and helpful. The authors have divided the failed Fontan patients into three groups: those undergoing Fontan takedown early after the Fontan operation, those undergoing the Fontan conversion procedure, and those undergoing heart transplantation. These are all critically ill patients with high mortality rates in all three groups. A summary of their results is shown in table 1 (Results of Surgical Intervention for the failing Fontan).1 The immediate conclusion looking at these numbers is that all of the surgical ‘rescue’ strategies have a very high early and late mortality.

There are multiple lessons to be learned from this analysis. At most centres all of the above operations are relatively rare occurrences. This collaborative effort helps demonstrate the power of multi-institutional studies. Aggregating the data from multiple centres helps clinicians and surgeons to understand the risks and benefits of these surgical strategies. The striking mortality in the three subgroups cries out for attention to optimise the strategies for care of these patients.

The operative mortality is particularly high for patients undergoing a Fontan takedown. Patients who have failed a Fontan operation in the early postoperative period are extremely ill. Some of this may be occurring because surgeons are attempting to ‘push the envelope’ and apply the Fontan procedure to increasingly complex patients with more and more risk factors for Fontan failure. We should keep in …