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Eur J Cardiothorac Surg 2003;24:255-259
© 2003 Elsevier Science NL

Surgical reinterventions following the Fontan procedure

^a Division of Cardiothoracic Surgery, The Cardiac Center at The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Suite 8527, Philadelphia, PA 19104, USA
^b Division of Cardiology, The Cardiac Center at The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Suite 8527, Philadelphia, PA 19104, USA
^c Division of Anesthesiology and Critical Care Medicine, The Cardiac Center at The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Suite 8527, Philadelphia, PA 19104, USA

Received 20 September 2002; received in revised form 24 March 2003; accepted 2 April 2003.

^* Corresponding author. Tel.: +1-215-590-2708; fax: +1-215-960-2715
e-mail: gaynor{at}email.chop.edu

	Abstract

Top Abstract 1. Introduction 2. Methods and patients 3. Results 4. Discussion References

 
Objective: The Fontan procedure is utilized as a final reconstructive procedure for patients with functional single ventricle. Short- and long-term outcomes have improved significantly, however, some patients require additional cardiac procedures following the Fontan operation. The outcomes for these reinterventions are not known. Methods: Cardiac Surgery and Cardiac Intensive Care Unit databases at The Children's Hospital of Philadelphia were reviewed to identify all patients who underwent cardiac surgery after a previous Fontan operation between January 1, 1995 and December 31, 2001. Results: During the study period, 123 procedures were performed in 71 patients. The median time from Fontan to reoperation was 3.6 years (range 0.1–20 years). Indications for reintervention included arrhythmia, cyanosis, ‘failing’ Fontan circulation or exercise intolerance, protein losing enteropathy, atrioventricular valve (AVV) regurgitation, and other indications. Procedures included pacemaker insertion or revision (n=59, 48%), reinclusion of previously excluded hepatic veins (n=16, 13%), revision to either a lateral tunnel or extra-cardiac conduit Fontan (n=13, 11%), cardiac transplantation (n=9, 7%), enlargement or creation of a baffle fenestration (n=6, 5%), isolated AVV repair or replacement (n=2, 2%), and other procedures (n=18, 14%). There were five early and five late deaths. Hospital mortality was greatest for patients undergoing cardiac transplantation (4/9, 44%), accounting for 80% of the early deaths. Conclusions: Surgical reinterventions following the Fontan procedure may be necessary for multiple indications which result in impairment of the Fontan circulation. Most reinterventions can be performed with minimal morbidity and mortality. Survival for patients requiring cardiac transplantation following the Fontan procedure remains poor.

Key Words: Fontan procedure • Reoperation • Protein losing enteropathy • Pacemaker • Heart transplantation

	1. Introduction

Top Abstract 1. Introduction 2. Methods and patients 3. Results 4. Discussion References

 
In recent years, management strategies for neonates and infants with functional single ventricle have evolved significantly. Most patients undergo a series of palliative procedures culminating in a modified Fontan operation. A variety of modifications of the Fontan operation have been introduced including staging with a superior cavopulmonary connection, baffle fenestration, the lateral tunnel Fontan procedure, and the extra-cardiac conduit Fontan procedure. Early mortality and morbidity following the Fontan operation have been dramatically reduced in recent years [1–5]. Long-term survival has also improved significantly, however, functional status may gradually deteriorate following the Fontan procedure [2,5]. A variety of factors including arrhythmias, atrioventricular valve (AVV) regurgitation, cyanosis, and ventricular dysfunction may impair the Fontan circulation and prompt reintervention [2–5]. The current study was undertaken to review our institutional experience with reoperation following Fontan operation, to describe the indications for subsequent surgical reintervention and to determine the early mortality and morbidity.

	2. Methods and patients

Top Abstract 1. Introduction 2. Methods and patients 3. Results 4. Discussion References

 
2.1. Patient population
The study was approved by the Institutional Review Board and the Committee for the Protection of Human Subjects at The Children's Hospital of Philadelphia. Review of the Cardiology and Cardiac Surgery databases at The Children's Hospital of Philadelphia identified 71 patients who underwent surgical reintervention following a modified Fontan operation between January 1, 1995 and December 31, 2001. Patients who underwent reintervention during the same hospitalization or within 30 days after their Fontan operation were excluded. Patients who underwent surgery for reasons not related to the Fontan circulation, such as postoperative infection or other organ systems (e.g. scoliosis) were also excluded. Patients who had undergone the Fontan operation at other institutions were included. Patients who underwent reoperation during the study period and had undergone prior reoperation before 1995 were also included. Medical records, operative notes, and Cardiac Intensive Care Unit (CICU) records were reviewed for all patients.

2.2. Patient-related variables
Demographic and anatomic variables were recorded from the medical record. Patients were assigned to one of six diagnostic groups on the basis of cardiac anatomy (Table 1). Details of the previous surgeries including staging, type of Fontan procedure (atriopulmonary connection, lateral tunnel, extra-cardiac conduit), as well as the use of baffle fenestration were also recorded.

2.4. Statistical analysis
Data are presented as medians and ranges. Specific outcomes evaluated for each procedure category included, hospital mortality (prior to hospital discharge or less than 30 days postoperatively), incidence of postoperative pleural effusions, duration of postoperative mechanical ventilation, duration of postoperative hospital stay, and postoperative complications. Late mortality and need for repeat reinterventions were also noted. Because of the variety of surgical indications and type of procedure, as well as the heterogeneity of the patient population, it was not possible to specifically evaluate predictors of need for reintervention or outcome.

	3. Results

Top Abstract 1. Introduction 2. Methods and patients 3. Results 4. Discussion References

 
Between January 1, 1995 and December 31, 2001, 123 procedures were performed in 71 patients who met inclusion criteria. There were 46 males and 25 females. Multiple procedures were performed in 30 patients with a maximum of nine for a single patient. Fourteen patients who had reoperations during the study period had undergone previous reintervention following their Fontan prior to 1995.

Cardiac diagnoses are presented in Table 1. Interim staging with a superior cavopulmonary connection had been utilized in 48 patients (68%). The median age at Fontan was 2.5 years (0.9–19 years). An atriopulmonary Fontan or variant had been performed in 17 of the patients (24%), a lateral tunnel Fontan in 49 patients (69%), and an extra-cardiac conduit Fontan in five patients (7%). Baffle fenestration had been performed in 22 patients (30%) and partial exclusion of the hepatic veins performed in an additional 16 patients (23%). The median time to the first reintervention was 3.6 years (range 0.1–20 years). Indications for reoperation included arrhythmia or pacemaker malfunction, cyanosis, ‘failing’ Fontan circulation, protein losing enteropathy (PLE), and AVV regurgitation (Table 2). Because of the heterogeneous nature and small number of many of the reoperations, it was not possible to determine if there was a correlation between diagnosis or type of Fontan procedure and need for reoperation except when partial exclusion of the hepatic veins had been performed. There were five early and five late deaths. Four of the five deaths occurred following cardiac transplantation secondary to graft dysfunction and/or multi-organ failure. The other occurred following Fontan revision in a patient with IVC occlusion and multi-organ failure prior to surgery.

3.1.2. Hepatic vein reinclusion
Sixteen patients underwent reinclusion of partially excluded hepatic veins for progressive cyanosis. The median time from Fontan was 3.6 years (range 0.4–6.5 years). The median duration of intubation was less than 1 day (range 0–2 days). The median duration of CICU stay was 1 day (range 1–19 days). The median duration of hospitalization was 7 days (range 3–36 days). Perioperative complications included complete heart block in one patient who underwent simultaneous tricuspid valve replacement, postoperative seizure in one patient, cardiac arrest at the time of anesthetic induction in one patient with no sequelae, and a pleural effusion requiring drainage in one patient.

3.1.3. Fontan revision
Thirteen patients underwent Fontan revision during the study period. A Maze procedure was performed in five patients and in five patients, concomitant AVV repair or replacement was performed. Indications included arrhythmia, pathway obstruction, ‘failing’ Fontan circulation, PLE, and AVV regurgitation. The Fontan had been an atriopulmonary connection or a variant in ten patients and lateral tunnel Fontan in three patients. Six patients were converted to a lateral tunnel type of Fontan, six patients were converted to an extra-cardiac conduit Fontan, and one patient was converted to intra-atrial conduit Fontan. The median time from Fontan to reoperation was 9 years (range 0.8–20 years). The median duration of intubation was 1 day (range 0–71 days). The median duration of CICU stay was 3 days (range 1–71 days). The median duration of hospitalization was 13 days (range 6–79 days). There was one hospital death and one late death. Postoperative complications included complete heart block in one patient undergoing AVV replacement, chylothorax in one patient, sepsis in two patients, acute renal failure in one patient, persistent PLE in one patient, and respiratory failure requiring tracheostomy in one patient.

3.1.4. Heart transplantation
Nine patients underwent heart transplantation during the study period. The indication was ‘failing’ Fontan circulation in six patients and unremitting PLE in three patients. The median time from Fontan to reoperation was 6 years (range 0.5–15 years). The median duration of intubation was 3 days (range 1–5 days). The median duration of CICU stay was 8 days (range 4–23 days). The median duration of hospitalization was 80 days (range 21–120 days). There were four perioperative deaths occurring at a median of 40 days posttransplant. In addition, one patient developed graft failure and recovered. One patient had stenosis at the superior vena cava (SVC) anastomosis, requiring placement of a stent. There have been two late deaths following transplantation.

3.1.5. Fenestration creation/enlargement
Five patients underwent six procedures for fenestration creation or enlargement. The indication in all patients was PLE. Fenestration of the original baffle was performed in four operations and a new fenestrated patch inserted during two operations. The median time from Fontan to reoperation was 5.6 years (range 5–13.7 years). The median duration of intubation was 1 day (range 0–1 day). The median duration of CICU stay was 2 days (range 1–16 days) with a median hospitalization of 9 days (range 6–46 days). Postoperative complications included a stroke in one patient and pneumothorax in one patient.

3.1.6. AVV repair/replacement
In addition to the five patients who underwent AVV interventions during the Fontan revision, two patients underwent two isolated AVV procedures. The indication was AVV regurgitation in both. The times from Fontan to reoperation were 0.3 years and 4.9 years. The durations of hospitalization were 15 and 18 days. Postoperative complications included a pleural effusion in one patient.

3.1.7. Other procedures
Fifteen other patients underwent a variety of other procedures including placement of a pericardial window for pericardial drainage, pleural drainage for late effusions, peripheral thrombectomy, reconstruction of discontinuous pulmonary arteries, repair of Fontan baffle leak, and two patients underwent takedown of the Fontan circulation to a superior cavopulmonary connection. There has been one late death following takedown of the Fontan.

	4. Discussion

Top Abstract 1. Introduction 2. Methods and patients 3. Results 4. Discussion References

 
Mortality and morbidity following the Fontan operation have been dramatically reduced in recent years [1–5]. Factors contributing to this improvement in early outcome include a variety of modifications of the Fontan circulation, including staging with an interim superior cavopulmonary connection, baffle fenestration, lateral tunnel Fontan procedure, and the extra-cardiac conduit Fontan procedure. A recent study from The Children's Hospital of Philadelphia evaluated early outcomes following the modified Fontan procedure in 332 patients between 1992 and 1999 [1]. Overall mortality was 6.6% and was less than 1% in the last 4 years of the study, despite a patient population comprising largely of patients with hypoplastic left heart syndrome (HLHS). Despite these encouraging early outcomes, patients remain at risk for late failure and complications of the Fontan circulation. The ‘natural history’ following the Fontan operation is largely unknown and continues to evolve as modifications of the operation are introduced [3–5]. In addition, the Fontan operation is currently performed in an increasing number of patients who previously would not have been considered appropriate candidates. Late complications of the Fontan circulation include baffle obstruction, arrhythmias, ventricular dysfunction, PLE, thromboembolic events, cyanosis, poor exercise tolerance, and AVV regurgitation [5]. The risk of complications requiring reintervention and the specific type of reintervention may be dependent on the type of Fontan connection created. It is possible that the incidence of reoperation will decrease as newer modifications of the Fontan connection such as the extra-cardiac connection are increasingly utilized, however, future studies will be necessary.

Kaulitz recently evaluated the need for late interventions in 88 patients followed for at least 5 years following a Fontan type operation [6]. Freedom from reoperation was 82% at 5 years and 76% at 8 years. During the follow-up period, 20 reoperations were performed. Indications for reoperation included anastomotic stenosis, atrial tachyarrhythmia, persistent cyanosis, chronic pericardial effusion, and ventricular outflow tract obstruction. Reoperations included revision of the Fontan pathway anastomosis (n=4), resection of the subaortic obstruction (n=3), closure of residual intra-atrial shunting (n=3), drainage of pericardial effusion (n=5), takedown of the Fontan to a superior cavopulmonary connection (n=1), aortic valve replacement (n=1), Fontan conversion (n=2), and reinclusion of the hepatic veins with an extra-cardiac conduit in a patient who had undergone the Kawashima operation (n=1). In addition, ten patients required placement of an epicardial pacemaker because of bradycardia.

The current study provides an overview of the types of reoperations performed following the Fontan operation in the current era and demonstrates that most reoperations can be accomplished with very low mortality and morbidity. The most common reoperations are related to pacemaker placement and revisions. Sinus node dysfunction is common following both the superior cavopulmonary connection and the Fontan procedure [7]. Patients are also at risk for atrial tachyarrhythmias including atrial flutter especially following atriopulmonary Fontan procedure [3,5,7]. In addition, atrial pacing has been advocated as a potential therapy for PLE [8]. Placement of a pacemaker may be difficult following a Fontan operation; epicardial placement of the leads may be necessary to avoid the risk of thrombosis of the Fontan pathway, lack of available atrial wall for placement of the lead, and inability to access the ventricular chamber [9]. Cohen and colleagues from The Children's Hospital of Philadelphia evaluated the incidence of sinus node dysfunction in 287 patients undergoing a staged Fontan operation between 1990 and 1995 [7]. Of the 95 patients followed for more than 4 years after the Fontan operation, 44% developed sinus node dysfunction. Cohen and colleagues also evaluated the risk of epicardial pacemaker implantation following the Fontan operation and found no difference in the perioperative course for Fontan patients compared to non-Fontan patients undergoing epicardial pacemaker lead placement [9]. There was no mortality in either group and no significant incidence of prolonged pleural effusions in the Fontan group.

Progressive cyanosis resulting from inter-atrial shunting, secondary to baffle fenestration or a baffle leak, may prompt reintervention either surgical or with transcatheter techniques. Previously, at our institution, partial exclusion of a hepatic vein was utilized instead of baffle fenestration. These patients have uniformly developed worsening cyanosis secondary to intra-hepatic shunting. In the current study, reinclusion of the excluded vein was necessary in 16 patients.

Patients in whom an atriopulmonary or atrioventricular Fontan was performed are at risk for progressive right atrial dilation with right atrial thrombus, pulmonary venous obstruction, and atrial tachyarrhythmias and may require revision to an extra-cardiac or intra-atrial conduit Fontan. Performance of a Maze operation and right atrial reduction in association with revision may decrease the severity of atrial arrhythmias, particularly atrial flutter. Marcelletti and associates reported outcome following revision to an extra-cardiac conduit in 31 patients from four institutions. There were two early deaths and one late death [10]. All surviving patients improved symptomatically except for one who ultimately required transplantation. The findings of the current study are similar suggesting that conversion operation can be performed in appropriately selected patients with low mortality and morbidity. These complications are likely to be less frequent in patients who initially underwent either the lateral tunnel Fontan operation or extra-cardiac Fontan operation. Stamm and colleagues from Boston Children's Hospital reported the outcome of 220 patients who underwent lateral tunnel Fontan completion between 1987 and 1991 [3]. There were 12 early deaths and seven late deaths. Four patients required takedown of the Fontan circulation and four patients underwent heart transplantation. The estimated survival was 93% at 5 years and 91% at 10 years with a freedom from failure of 90% at 5 years and 87% at 10 years.

Cardiac transplantation is sometimes necessary for ventricular dysfunction and failure of the Fontan circulation. In the current study, nine patients underwent cardiac transplantation with four deaths resulting in an operative mortality of 44%. Carey and associates reported outcomes for cardiac transplantation in nine patients (four adults and five children) with a failing Fontan circulation [11]. The operative mortality was 33% with eight early deaths, secondary to graft failure in two cases and postoperative hemorrhage in the other. Early mortality for patients with the Fontan circulation undergoing cardiac transplantation is greater than other patients with congenital heart disease or those with cardiomyopathy. The patients are often severely debilitated with poor nutritional status. Repeat sternotomy in patients who have undergone multiple previous operations is associated with an increased risk of postoperative hemorrhage. Complex reconstruction of the pulmonary arteries, as well as the systemic and pulmonary veins is often necessary. In addition, transplantation is often performed for patients with PLE, which may not resolve following transplantation. Nevertheless transplantation may be the only therapeutic option for patients with a ‘failing’ Fontan circulation.

PLE is a particularly difficult problem following the Fontan and is often resistant to therapy [12]. In addition to transplantation, several patients with PLE in the current series underwent baffle fenestration and placement of an atrial pacemaker [8,13]. These interventions are designed to increase systemic output and mesenteric perfusion. These interventions can be safely accomplished but the long-term results are less satisfactory.

There are several limitations to the current study. It is retrospective and evaluates reoperation for all patients during a specific era rather than longitudinally evaluating a cohort of patients. The study addresses only the short-term outcomes and not the long-term effectiveness of the intervention. For example, PLE may not resolve following ‘successful’ baffle fenestration or ‘successful’ cardiac transplantation resulting in a poor long-term outcome despite a technically successful reoperation. In addition, the patient population is relatively small and heterogeneous with a large variety of reoperations precluding statistical analysis of predictors of outcome.

The current study demonstrates that a variety of reoperations may be required following the Fontan operation. The most common procedures are related to pacemaker insertion and revision. Most reoperations can be accomplished with minimal mortality and morbidity. The outcome for patients who require cardiac transplantation following the Fontan operation remains poor.

	Footnotes

 
Presented at the 16th Annual Meeting of the European Association for Cardio-thoracic Surgery, Monte Carlo, Monaco, September 22–25, 2002.

	References

Top Abstract 1. Introduction 2. Methods and patients 3. Results 4. Discussion References

 

1. Gaynor J.W., Bridges N.D., Cohen M.I., Mahle W.T., DeCampli W.M., Steven J.M., Nicolson S.C., Spray T.L. Predictors of outcome after the Fontan operation: is hypoplastic left heart syndrome still a risk factor?. J Thorac Cardiovasc Surg 2002;123:237-245.[Abstract/Free Full Text]
2. Gentles T.L., Mayer J.E., Gauvreau K., Newburger J.W., Lock J.E., Kupferschmid J.P., Burnett J., Jonas R.A., Castaneda A.R., Wernovsky G. Fontan operation in five hundred consecutive patients: factors influencing early and late outcome. J Thorac Cardiovasc Surg 1997;114:376-391.[Abstract/Free Full Text]
3. Stamm C., Friehs I., Mayer J.E., Zurakowski D., Triedman J.K., Moran A.M., Walsh E.P., Lock J.E., Jonas R.A., del Nido P.J. Long-term results of the lateral tunnel Fontan operation. J Thorac Cardiovasc Surg 2001;121:28-41.
4. Mair D.D., Puga F.J., Danielson G.K. The Fontan procedure for tricuspid atresia: early and late results of a 25-year experience with 216 patients. J Am Coll Cardiol 2001;37:933-939.[Abstract/Free Full Text]
5. Freedom R.M., Hamilton R., Yoo S.-J., Mikailian H., Benson L., McCrindle B., Justino H., Williams W.G. The Fontan procedure: analysis of chorts and late complications. Cardiol Young 2000;10:307-331.[Medline]
6. Kaulitz R., Ziemer G., Paul T., Peuster M., Bertram H., Hausdorf G. Fontan-type procedures: residual lesions and late interventions. Ann Thorac Surg 2002;74:778-785.[Abstract/Free Full Text]
7. Cohen M.I., Wernovsky G., Vetter V.L., Wieand T.S., Gaynor J.W., Jacobs M.L., Spray T.L., Rhodes L.A. Sinus node function after a systemically staged Fontan procedure. Circulation 1998;98:II-352-IIhyphen359.
8. Cohen M.I., Rhodes L.A., Wernovsky G., Gaynor J.W., Spray T.L., Rychik J. Atrial pacing: an alternative treatment for protein-losing enteropathy after the Fontan operation. J Thorac Cardiovasc Surg 2001;121:582-583.[Free Full Text]
9. Cohen M.I., Vetter V.L., Wernovsky G., Bush D.M., Gaynor J.W., Iyer V.R., Spray T.L., Tanel R.E., Rhodes L.A. Epicardial pacemaker implantation and follow-up in patients with a single ventricle after the Fontan operation. J Thorac Cardiovasc Surg 2001;121:804-811.[Abstract/Free Full Text]
10. Marcelletti C.F., Hanley F.L., Mavroudis C., McElhinney D.B., Abella R.F., Marianeschi S.M., Seddio F., Reddy V.M., Petrossian E., del la Torre T., Colagrande L., Backer C.L., Cipriani A., Iorio F.S., Fontan F. Revision of previous Fontan connections to total extracardiac cavopulmonary anastomosis: a multicenter experience. J Thorac Cardiovasc Surg 2000;119:340-346.[Abstract/Free Full Text]
11. Carey J.A., Hamilton J.R.L., Hilton C.J., Dark J.H., Forty J., Parry G., Hasan A. Orthotopic cardiac transplantation for the failing Fontan scirculation. Eur J Cardiothorac Surg 1998;14:7-14.
12. Mertens L., Hagler D.J., Sauer U., Somerville J., Gewillig M. Protein-losing enteropathy after the Fontan operation: an international multicenter study. J Thorac Cardiovasc Surg 1998;115:1063-1073.[Abstract/Free Full Text]
13. Rychik J., Rome J.J., Jacobs M.L. Late surgical fenestration for complications after the Fontan operation. Circulation 1997;96:33-36.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): J. William Gaynor Thomas L. Spray Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Petko, M. Articles by Spray, T. L. Search for Related Content PubMed PubMed Citation Articles by Petko, M. Articles by Spray, T. L. Related Collections Congenital - cyanotic Congestive Heart Failure Electrophysiology - arrhythmias Transplantation - heart