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Marathe SP, Zannino D, Shi WY, du Plessis K, Kehr J, Perumal G, Sun J, Gentles TL, Ayer J, Sholler GF, Verrall CE, Alphonso N, Andrews D, d'Udekem Y, Winlaw DS. Two Ventricles Are Not Better Than One in the Fontan Circulation: Equivalent Late Outcomes. Ann Thorac Surg 2018; 107:852-859. [PMID: 30300642 DOI: 10.1016/j.athoracsur.2018.08.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 08/06/2018] [Accepted: 08/13/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND A subset of patients who underwent Fontan operations has two adequate-sized ventricles, but an anatomic biventricular circulation cannot be achieved because of complex morphology or for technical reasons. This study sought to determine whether these patients with two-ventricle Fontan circulation had superior outcomes compared with those with a single ventricle. METHODS A binational Fontan Registry of patients (n = 1,377) was analyzed to identify those patients with two adequate ventricles. This cohort was compared with patients with single-ventricle Fontan circulation. The primary end point was a composite end point called "Fontan failure" encompassing death, heart transplantation, Fontan takedown or conversion, protein-losing enteropathy, plastic bronchitis, or New York Heart Association functional class III or IV. RESULTS A total of 79 Fontan patients with two adequate ventricles (2V) were compared with 1,291 single ventricle (1V) Fontan patients. Median follow-up for the entire cohort was 11.5 years (interquartile range, 5.1 to 18.8 years). There was no difference in unadjusted 15-year freedom from Fontan failure (2V: 81% [95% confidence interval (CI), 69% to 94%] vs 1V: 86% [95% CI, 83% to 88%], p = 0.4). Propensity-score matching for potential confounding factors yielded 75 two-ventricle Fontan patients matched with 604 single-ventricle Fontan patients, in which 15-year freedom from Fontan failure was also not different (2V: 79% [95% CI, 67% to 94%] vs 1V: 87% [95% CI, 84% to 91%], p = 0.3). CONCLUSIONS The two-ventricle Fontan circulation does not have better outcomes compared with the single-ventricle Fontan circulation. Late outcomes may depend more on other characteristics of the Fontan circulation. This finding is relevant when the Fontan procedure is being considered as an alternative to anatomic repair in patients with complex two-ventricle morphologies.
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Affiliation(s)
- Supreet P Marathe
- Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia
| | - Diana Zannino
- Murdoch Children's Research Institute, Melbourne, Australia
| | - William Y Shi
- Department of Cardiothoracic Surgery, Monash Medical Centre, Melbourne, Australia
| | - Karin du Plessis
- Murdoch Children's Research Institute, Melbourne, Australia; Department of Pediatrics, Faculty of Medicine, University of Melbourne, Melbourne, Australia
| | - Jascha Kehr
- Starship Green Lane Pediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand
| | - Gopinath Perumal
- Queensland Pediatric Cardiac Service, Lady Cilento Children's Hospital, Brisbane, Australia
| | - Jessica Sun
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Thomas L Gentles
- Starship Green Lane Pediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand
| | - Julian Ayer
- Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia; School of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Gary F Sholler
- Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia; School of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Charlotte E Verrall
- Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia
| | - Nelson Alphonso
- Queensland Pediatric Cardiac Service, Lady Cilento Children's Hospital, Brisbane, Australia
| | - David Andrews
- Department of Cardiothoracic Surgery, Princess Margaret Hospital, Perth, Australia
| | - Yves d'Udekem
- Murdoch Children's Research Institute, Melbourne, Australia; Department of Pediatrics, Faculty of Medicine, University of Melbourne, Melbourne, Australia; Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia
| | - David S Winlaw
- Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia; School of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, Australia.
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