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J Thorac Cardiovasc Surg 2004;128:60-66
© 2004 The American Association for Thoracic Surgery

Surgery for congenital heart disease

The failing Fontan circulation: Successful conversion of atriopulmonary connections

^a Department of Cardiac Surgery, the Wessex Regional Cardiac and Thoracic Unit, Southampton General Hospital, Southampton, United Kingdom
^b Department of Cardiology, the Wessex Regional Cardiac and Thoracic Unit, Southampton General Hospital, Southampton, United Kingdom
^c Department of Research and Development, the Wessex Regional Cardiac and Thoracic Unit, Southampton General Hospital, Southampton, United Kingdom
^d Department of Thoracic Surgery, Duke University Medical Center, Durham, NC, USA

Some of the data displayed in this article were presented at the EACTS Meeting, Frankfurt, Germany, October 7-11, 2000.

Received for publication September 9, 2003; revisions received February 9, 2004; accepted for publication February 26, 2004.

^* Address for reprints: Marcus P. Haw, MBBS, MS, FRCS, FECTS, Department of Cardiac Surgery, Southampton General Hospital, Tremona Rd, Southampton SO16 6YD, United Kingdom
marcushaw{at}hotmail.com

OBJECTIVES: 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 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.

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