Heart transplant for failing fontan with situs inversus and aortic aneurysm: Utilization of lateral tunnel fontan pathway for systemic venous reconstruction

Heart transplant indications, considerations and outcomes in Fontan patients: Age-related nuances, transplant listing and disease-specific indications

In the current era, 5-10% of Fontan patients die or need a transplant in childhood, and approximately 50% will experience the same fate by age 40 years. Heart transplant (HTx) can be successful for selected children and adults with Fontan circulatory failure (FCF) of any mechanism, with a 1-year post-transplant survival approaching 90% in children and 80% in the largest single-centre adult Fontan HTx experience. Protein losing enteropathy and plastic bronchitis can be expected to resolve post-transplant and limited data suggests patients with FALD who survive HTx can expect improvement in liver health. Early Fontan failure, within 12 months of Fontan completion, is not easily rescued by HTx and late referrals / failure to refer adult patients remains problematic. Very little is known about the numbers of patients not referred, turned down following assessment for HTx, or dying on the waiting list which are needed to understand the complete picture of HTx in the Fontan population and to identify where best to focus quality improvement efforts. Recent revisions to listing prioritization in Canada with considerations specific to the Fontan population aim to mitigate the fact that the status listing criteria are not tailored to the congenital heart population. Transplanting high-risk children prior to Fontan completion, developing ACHD transplant centres of expertise which can also offer combined heart-liver transplant when appropriate, and improving single ventricle mechanical support options and criteria for both adults and children may help mitigate the early post-listing mortality.