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J Thorac Cardiovasc Surg 2005;129:491-495
© 2005 The American Association for Thoracic Surgery

Editorials

The Fontan operation, thromboembolism, and anticoagulation: A reappraisal of the single bullet theory

Section of Cardiothoracic Surgery, St Christopher's Hospital for Children, Department of Cardiothoracic Surgery, Drexel University College of Medicine, Philadelphia, Pa

Received for publication September 20, 2004; accepted for publication September 28, 2004.

^* Address for reprints: Marshall L. Jacobs, MD, St Christopher's Hospital for Children, Erie Ave at Front St, Philadelphia, PA 19134 (E-mail: Marshall.Jacobs@tenethealth.com).

The first 300 words of the full text of this article appear below.

During the more than 3 decades that have transpired since the earliest reports of "corrective surgery" for tricuspid atresia by Fontan and Baudet¹ and Kreutzer and colleagues,² the general principles of their operations have increasingly been applied to a wide spectrum of cardiovascular anomalies characterized by a functional single ventricle or nonseptatable heart. These surgical reconstructions, culminating in diversion of systemic venous return directly to the pulmonary arteries, are generally referred to as modified Fontan procedures. The earliest of these operations were technically complicated affairs with intentional implantation of valves in the venous pathways and frequent use of conduits made from various prosthetic and biologic materials. Over 30 years, the operations have evolved in a direction characterized by technical simplification of the pathways and procedures. Currently, modified Fontan procedures are really total cavopulmonary connections. The use of prosthetic materials has been minimized but not eliminated. Valves are no longer integrated into the venous pathways. The completed Fontan procedure is most often, although not always, achieved in 2 steps with a hemi-Fontan or superior cavopulmonary anastomosis, which is ultimately followed by a completion Fontan procedure that directs inferior caval flow to the pulmonary arteries, either entirely by extracardiac connections or by an intraatrial tunnel. The trend in operative mortality for modified Fontan procedures has been one of steady improvement from mortality rates of 25% to 30% in the earliest series to less than 5% in contemporary reports. Despite this record of progress, some factors contributing to morbidity and mortality persist. One of the major factors contributing to morbidity and failure of the Fontan circulation is the group of events referred to as thromboembolic complications. This vexing problem, and in particular the question of the potential benefit of prophylactic anticoagulant therapy in patients who undergo the Fontan operation, is the subject of . . . [Full Text of this Article]

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