The failing Fontan circulation: successful conversion of atriopulmonary connections.
OBJECTIVE
Symptoms from low cardiac output or refractory atrial arrhythmias are complicating atriopulmonary (classical) Fontan connections. We present our experience of converting such patients to total cavopulmonary connections with and without arrhythmia surgery.


METHODS
Between 1997 and 2002, 15 patients (mean age, 19.7 +/- 7.0 years) underwent conversion operations 12.7 +/- 3.5 years after atriopulmonary Fontan operations. Preoperative New York Heart Association functional class was I in 2 patients, II in 2 patients, III in 6 patients, and IV in 5 patients. Four patients underwent intracardiac lateral tunnel conversion alone, and 11 received extracardiac total cavopulmonary connection, right atrial reduction, and cryoablation.


RESULTS
No mortality occurred. One patient had conduit obstruction in the immediate postoperative period requiring replacement, and another required a redo operation for endocarditis. Average hospitalization was 17.9 +/- 9.38 days; chest drains were removed on median day 4 (range, 1-29; mean, 7.4 +/- 7.58 days). At follow-up (mean, 42.6 +/- 22.1 months), late atrial arrhythmias had recurred in 3 of 4 patients with intracardiac total cavopulmonary connections (without ablation) and 1 of 11 patients with extracardiac total cavopulmonary connections with ablation. All patients are in New York Heart Association class I or II. Exercise ability (Bruce protocol) improved 69% from a mean of 6.18 +/- 4.01 minutes to 10.45 +/- 2.11 minutes (P <.05). Need for antiarrhythmic agents decreased postoperatively (patients receiving < or =1 antiarrhythmic: 9 preoperatively vs 15 at long-term follow-up, P <.05). No patient has required transplantation. Protein-losing enteropathy, which was present in 1 patient, improved transiently with conversion. There was 1 late death from gastrointestinal hemorrhage.


CONCLUSIONS
Fontan conversion can be achieved with low mortality and improvement in New York Heart Association class and exercise ability. Concomitant arrhythmia surgery reduces the incidence of late arrhythmias.
Sheikh
A M
AM
Department of Cardiac Surgery, Wessex Regional Cardiac and Thoracic Unit, Southampton General Hospital, Southampton, United Kingdom.
Tang
A T M
AT
Roman
K
K
Baig
K
K
Mehta
R
R
Morgan
J
J
Keeton
B
B
Gnanapragasam
J
J
Vettukattil
J V
JV
Salmon
A P
AP
Monro
J L
JL
Haw
M P
MP
D000293:Adolescent; D000328:Adult; D001145:Arrhythmias, Cardiac / Q000209:etiology / Q000401:mortality / Q000503:physiopathology; D004310:Double Outlet Right Ventricle / Q000601:surgery; D022062:Electrophysiologic Techniques, Cardiac; D017079:Exercise Tolerance / Q000502:physiology; D005260:Female; D005500:Follow-Up Studies; D018729:Fontan Procedure; D006325:Heart Atria / Q000503:physiopathology / Q000601:surgery; D006345:Heart Septal Defects, Ventricular / Q000601:surgery; D006801:Humans; D008297:Male; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality / Q000503:physiopathology* / Q000601:surgery*; D018633:Pulmonary Atresia / Q000601:surgery; D011652:Pulmonary Circulation / Q000502:physiology; D012086:Reoperation; D016019:Survival Analysis; D013997:Time Factors; D017211:Treatment Failure; D018785:Tricuspid Atresia / Q000601:surgery