title: Intra/extracardiac fenestrated modification leads to lower incidence of arrhythmias after the Fontan operation.
abstract: OBJECTIVE
  The study objective was to compare the incidence of short- and intermediate-term arrhythmias among 3 different surgical modifications of the Fontan procedure.
  
  
  METHODS
  We performed a retrospective review of all patients who underwent the Fontan operation at a single institution between January 2004 and May 2010 for preoperative, perioperative, and follow-up variables. Three surgical modifications were studied: intra/extracardiac conduit with limited atriotomy, standard extracardiac conduit, and lateral tunnel. Rhythm was classified as normal or abnormal. A rhythm dysfunction grading was devised and used to identify worsening of rhythm for patients with abnormal rhythm preoperatively. Multivariable logistic regression was used to determine predictors of abnormal rhythm. To eliminate confounding effects of transient immediate postoperative arrhythmias, data were analyzed for abnormal rhythm within the first 2 weeks and for more than 2 weeks after surgery.
  
  
  RESULTS
  Of the 134 patients (n = 50 with intra/extracardiac conduit with limited atriotomy, n = 19 with standard extracardiac conduit, n = 65 with lateral tunnel) (median follow-up, 36 months; interquartile range, 22-50 months; 2 operative deaths and 6 late deaths), rhythm data for more than 2 weeks postoperatively were available in 88 (40 with lateral tunnel, 14 with standard extracardiac conduit, 34 with intra/extracardiac conduit with limited atriotomy). These patients constituted the study groups. Patients in the lateral tunnel group were relatively younger at the time of the Fontan operation (P < .001) and had a longer follow-up (P < .001). Multivariable logistic regression confirmed that greater than moderate atrioventricular valve regurgitation was the only independent predictor of abnormal rhythm during the first 2 postoperative weeks. Older age at Fontan (odds ratio, 1.20; 95% confidence interval, 1.05-1.38; P = .012) and higher preoperative mean pulmonary artery pressure (odds ratio, 1.2; 95% confidence interval, 1.03-1.44; P = .026) were predictors of abnormal rhythm more than 2 weeks postoperatively. Intra/extracardiac conduit with limited atriotomy Fontan modification was associated with a significantly lower incidence of abnormal rhythm after 2 weeks postoperatively compared with lateral tunnel modification (odds ratio, 0.28; 95% confidence interval, 0.10-0.84; P = .015).
  
  
  CONCLUSIONS
  Intra/extracardiac conduit with limited atriotomy Fontan modification has a significantly lower risk of abnormal rhythm postoperatively in the short and intermediate term when compared with the lateral tunnel.
authors.affiliation: Cardiovascular Surgery, Children's National Medical Center, Washington, DC 20010, USA.
authors.forename: Pranava
authors.initials: P
authors.lastname: Sinha
authors.forename: David
authors.initials: D
authors.lastname: Zurakowski
authors.forename: Dingchao
authors.initials: D
authors.lastname: He
authors.forename: Can
authors.initials: C
authors.lastname: Yerebakan
authors.forename: Vicki
authors.initials: V
authors.lastname: Freedenberg
authors.forename: Jeffrey P
authors.initials: JP
authors.lastname: Moak
authors.forename: Richard A
authors.initials: RA
authors.lastname: Jonas
mesh_terms: D000293:Adolescent; D001145:Arrhythmias, Cardiac / Q000453:epidemiology*; D002648:Child; D002675:Child, Preschool; D004562:Electrocardiography; D005260:Female; D018729:Fontan Procedure / Q000379:methods*; D006330:Heart Defects, Congenital / Q000601:surgery*; D006801:Humans; D015994:Incidence; D007223:Infant; D016015:Logistic Models; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D015996:Survival Rate; D016896:Treatment Outcome