The Annals of Thoracic Surgery
Volume 112, Issue 1, P179-187, July 01, 2021, DOI: https://doi.org/10.1016/j.athoracsur.2020.05.174
John D. Serfas, MD, Dylan Thibault, MS, Nicholas D. Andersen, MD, Karen Chiswell, PhD, Jeffrey P. Jacobs, MD, Marshall L. Jacobs, MD, Richard A. Krasuski, MD, Andrew J. Lodge, MD, Joseph W. Turek, MD, PhD, Kevin D. Hill, MD, MSCI
Fontan failure often requires surgical therapy in the form of Fontan revision or heart transplantation. We sought to characterize national trends in the surgical burden of Fontan failure and identify risk factors for adverse outcomes.
Fontan patients undergoing Fontan revision or transplantation from January 2010 to June 2018 were included. We evaluated baseline characteristics and outcomes and used multivariable logistic regression to identify risk factors for operative mortality and composite mortality and major morbidity.
A total of 1135 patients underwent Fontan revision (n = 598) or transplantation (n = 537) at 100 centers. Transplantations increased from 34 in 2010 to 76 in 2017, largely owing to an increase in patients with hypoplastic left heart syndrome (HLHS) (18 in 2010 to 49 in 2017), while Fontan revision decreased (75 in 2010 to 49 in 2017). Transplantation patients were younger (median 14 years of age vs 18 years of age; P < .001), more often had preoperative risk factors (66% vs 40%; P < .001), and more often had HLHS (51% vs 15%; P < .001). Operative mortality and composite major morbidity and mortality were 7.6% and 35% for transplantation and 7.1% and 22% for Fontan revision, respectively. Multivariable risk factors for mortality included older age (odds ratio [OR], 1.08/y; P = .007), presence of preoperative risk factors (OR, 3.33; P = .002), and concomitant pulmonary artery reconstruction (OR, 2.7; P = .029) for Fontan revision but only older age (OR, 1.06/y; P = .020) for transplantation.
Both transplantation and Fontan revision are associated with high morbidity and mortality. There has been evolution of practices in surgical therapy for Fontan failure, perhaps related to rising prevalence of HLHS staged palliation.
This study by Serfas et al documents the evolving burden of Fontan failure as represented by patients identified from an analysis of the STS Congenital Heart Surgery Database (STS-CHSD) who required either Fontan revision surgery or heart transplantation from 2010 to 2018. The study aimed to characterize the 2 populations of failing Fontan patients requiring either of these interventions, to delineate risk factors associated with adverse post-operative outcomes and elucidate the evolving use of both Fontan revision surgery and heart transplantation in managing this challenging patient cohort. Interestingly, overall outcomes were remarkably similar with operative survival of 7.1% for Fontan revision and 7.6% for heart transplantation. Trends over time indicated increasing use of heart transplantation and declining use of Fontan conversion with heart transplantation becoming the more common procedure from end 2013 onwards, despite often quite different indications for the 2 surgical strategies. Overall annual procedural numbers did not appear to change substantially over the duration of the study (average approximately 100-120 cases/yr). Mu. Overall, the study is a very useful delineation of the evolving surgical approach to a challenging but diverse patient cohort who may have either structural or circulatory reasons for Fontan failure. It nicely demonstrates trends occurring over time with increasing use of heart transplantation rather than structural Fontan revisions +/- arrhythmia surgery to address the multifaceted aspects of Fontan failure. Subgroup analysis clearly defines a shift from 2015 onwards towards utilizing heart transplantation in the context of HLHS with failing Fontan physiology. It would be anticipated that heart transplantation will increasingly be utilized as the 4th stage of palliation in individuals with HLHS as this population continues to grow with successful early staged palliation.