Current management of late failure after classic Fontan modifications: Fontan conversion.
BACKGROUND
Re-establishment of Fontan circulation by eliminating the drawbacks of classic Fontan modifications has been proposed recently to improve the functional class and quality of life of patients with failed Fontan circulation.


METHODS
Five patients underwent extracardiac and lateral tunnel Fontan conversion due to failure of the Fontan circulation, after classic Fontan modifications. All of the patients were female and mean age was 10.2 +/- 2.2 years (range: 8-14 years). Previous Fontan modifications were atrio-pulmonary anastomosis in 3 and Kawashima operation in 2 patients. Time to re-operation for Fontan conversion was 6 +/- 1.5 years (range: 4-8 years). Indications for re-operation were right heart failure, right atrial dilatation, and intractable atrial arrhythmias in patients with previous atrio-pulmonary anastomosis, progressive hypoxia and exercise intolerance in patients with previous Kawashima operation due to pulmonary arteriovenous fistulas. Previous atrio-pulmonary anastomoses were converted to intra-atrial or lateral tunnel Fontan operation with modified right atrial Maze procedure. Extracardiac Fontan completion was carried out after previous Kawashima operations by redirection of hepatic veins to the lungs.


RESULTS
There was no mortality and no major morbidity. All patients were discharged from the hospital in good condition and in sinus rhythm. No prolonged or recurrent effusions were observed. On follow-up, all patients were in sinus rhythm and had NYHA class I functional capacity. In two Kawashima patients, SpO(2) gradually increased from 60 % to 90 % six months after the operation.


CONCLUSIONS
We suggest that Fontan conversion should be considered in patients with previous atrio-pulmonary anastomosis, when right atrial dilatation or intractable atrial arrhythmias with deteriorating functional status develops. Redirection of hepatic venous flow to lungs induces regression of pulmonary arteriovenous fistulas and improves arterial saturation in patients with previous Kawashima operation.
Acibadem Hospital Bakirkoy, Department of Cardiovascular Surgery, Bakirkoy, Istanbul, Turkey.
E
E
Erek
Y K
YK
Yalcinbas
A
A
Sarioglu
T
T
Sarioglu
D000293:Adolescent; D000714:Anastomosis, Surgical; D001164:Arteriovenous Fistula / Q000601:surgery; D002648:Child; D004108:Dilatation, Pathologic / Q000209:etiology / Q000601:surgery; D017079:Exercise Tolerance; D005260:Female; D005500:Follow-Up Studies; D018729:Fontan Procedure / Q000009:adverse effects* / Q000379:methods*; D006325:Heart Atria / Q000002:abnormalities / Q000601:surgery; D006333:Heart Failure / Q000209:etiology / Q000601:surgery; D006801:Humans; D000860:Hypoxia / Q000209:etiology / Q000601:surgery; D007902:Length of Stay; D011667:Pulmonary Veins / Q000002:abnormalities / Q000601:surgery; D011788:Quality of Life; D012086:Reoperation; D013610:Tachycardia / Q000209:etiology / Q000601:surgery; D013997:Time Factors; D017211:Treatment Failure; D014683:Vena Cava, Superior / Q000601:surgery