Management of early Fontan failure: a single-institution experience†

OBJECTIVE: To analyse the incidence and outcomes of early Fontan failure (EFF) in a large contemporary cohort of palliated patients. METHODS: A retrospective, single-centre study of all patients undergoing primary Fontan from 1 July 1995 to 31 December 2009 was per-formed. EFF was defined as death, need for extracorporeal membrane oxygenation (ECMO), Fontan takedown to superior cavopulmonary connection (SCPC) or transplantation within 30 days of the Fontan procedure. The incidence and outcomes were summarized with de-scriptive statistics, and risk factors for EFF were identified. RESULTS: A total of 592 patients underwent primary Fontan procedure during the study period; 67 % had a dominant right ventricle. An extracardiac conduit (ECC) was used for Fontan completion in 60.5%, with the remainder having a lateral tunnel. EFF occurred in 11 patients (1.9%), all of whom had ECC. ECMO was used in 5 patients, 5 had Fontan takedown and 2 had heart transplantation. Five of eleven, or 46%, study subjects died as opposed to an overall mortality for primary Fontan of 0.8%. Among patients who had Fontan take-down to SCPC, long-term survival was 80%. By univariate analysis, elevated ventricular end-diastolic pressure (9.5 ± 3.3 vs 7.4 ± 2.7 mmHg, P = 0.019) and total circulatory support time (99 ± 33 vs 71 ± 23 min, P = 0.001) were risk factors for EFF. The mean follow-up for the 6 hos-pital survivors was 5.9 years. There was one late transplant-related death. Of the 4 surviving patients who had Fontan takedown to a SCPC, 3 underwent subsequent Fontan completion and 1 underwent biventricular repair. CONCLUSIONS: EFF is rare in the current era, but is associated with significant mortality. High filling pressures and a prolonged intraopera