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King G, Buratto E, Cordina R, Iyengar A, Grigg L, Kelly A, Bullock A, Ayer J, Alphonso N, d'Udekem Y, Konstantinov IE. Atrioventricular septal defect in Fontan circulation: Right ventricular dominance, not valve surgery, adversely affects survival. J Thorac Cardiovasc Surg 2023; 165:424-433. [PMID: 36008181 DOI: 10.1016/j.jtcvs.2022.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 03/01/2022] [Accepted: 04/05/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The effect of ventricular dominance and previous atrioventricular valve (AVV) surgery on patient outcomes after Fontan operation remains unclear. We sought to determine the effect of ventricular dominance and previous AVV surgery on transplantation-free survival and long-term AVV competency in patients with atrioventricular septal defect (AVSD) and Fontan circulation. METHODS We conducted a retrospective study of 1703 patients in the Australia and New Zealand Fontan Registry, who survived Fontan operation between 1987 and 2021. RESULTS Of 174 patients with AVSD, 60% (105/174) had right ventricular (RV) dominance and 40% (69/174) had left ventricular (LV) dominance. The cumulative incidence of moderate or greater AVV regurgitation at 25 years after Fontan operation in patients with LV dominance was 56% (95% CI, 35%-72%), compared with 54% (95% CI, 40%-67%) in patients with RV dominance (P = .6). Nonetheless, transplantation-free survival at 25 years in patients with LV dominance was 94% (95% CI, 86%-100%), compared with 67% (95% CI, 52%-87%) in patients with RV dominance (hazard ratio, 5.9; 95% CI, 1.4-25.4; P < .01). Of note, transplantation-free survival was not different in patients who underwent AVV surgery before or at Fontan completion compared with those who did not (15 years: 81% [95% CI, 62%-100%] vs 88% [95% CI, 81%-95%]; P = .3). CONCLUSIONS In patients with AVSD and Fontan circulation the rate of moderate or greater common AVV regurgitation is similar in those with LV and RV dominance. RV dominance, rather than previous AVV surgery, is a risk factor for death or transplantation.
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Affiliation(s)
- Gregory King
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia
| | - Edward Buratto
- Department of Paediatrics, University of Melbourne, Melbourne, Australia; Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Department of Cardiac Surgery, The Royal Melbourne Hospital, Melbourne, Australia
| | - Rachael Cordina
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia; Heart Research Institute, Newtown, Sydney, Australia
| | - Ajay Iyengar
- Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Health, Auckland, New Zealand; Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Leeanne Grigg
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Andrew Kelly
- Department of Cardiology, Women's and Children's Hospital, Adelaide, Australia; Faculty of Health and Medical Sciences, Department of Paediatrics, The University of Adelaide, Adelaide, Australia
| | - Andrew Bullock
- Department of Cardiology, Perth Children's Hospital, Perth, Australia; Division Cardiovascular Medicine, Adult Congenital Cardiology, Sir Charles Gardiner Hospital, Perth, Australia
| | - Julian Ayer
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia; Discipline of Paediatrics and Child Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Nelson Alphonso
- Department of Cardiac Surgery, Queensland Children's Hospital, Brisbane, Australia; Queensland Paediatric Cardiac Research, Child Health Research Centre, University of Queensland, Brisbane, Australia
| | - Yves d'Udekem
- The Division of Cardiovascular Surgery, Children's National Heart Institute, Washington, DC
| | - Igor E Konstantinov
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Melbourne Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne, Australia.
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Venna A, d’Udekem Y. OUP accepted manuscript. Interact Cardiovasc Thorac Surg 2022; 35:6513625. [PMID: 35061891 PMCID: PMC9252110 DOI: 10.1093/icvts/ivab369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 12/08/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Alyssia Venna
- Division of Cardiac Surgery, Children’s National Hospital, Washington, DC, USA
| | - Yves d’Udekem
- Division of Cardiac Surgery, Children’s National Hospital, Washington, DC, USA
- Corresponding author. Division of Cardiac Surgery, Children’s National Hospital, 111 Michigan Ave., NW, Suite W3-402, Washington, DC 20010, USA. Tel: +1-202-476-2811; fax: +1-202-476-5572; e-mail: (Y. d’Udekem)
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Atrioventricular Valve Failure in Fontan Palliation. J Am Coll Cardiol 2020; 73:810-822. [PMID: 30784675 DOI: 10.1016/j.jacc.2018.12.025] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 11/29/2018] [Accepted: 12/10/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Atrioventricular valve failure (moderate or greater regurgitation, or valve operation) is a risk factor for adverse outcomes in patients undergoing Fontan palliation. OBJECTIVES This study determined the incidence of atrioventricular valve failure and its clinical impact on patients undergoing Fontan palliation. METHODS A retrospective cohort longitudinal study was conducted using patient data extracted from an existing bi-national, population-based registry. RESULTS A total of 1,468 patients who underwent Fontan palliation were identified; complete follow-up data were available for 1,199 patients. Six hundred eighty-six patients had 2 atrioventricular valves, 286 had a single mitral valve, 130 had a common atrioventricular valve, and 97 had a single tricuspid valve. A total of 132 repairs were performed in 110 patients, and 15 replacements were performed in 13 patients. The cumulative incidence of atrioventricular valve failure at 25 years of age for patients with a common atrioventricular, single tricuspid, single mitral, and 2 atrioventricular valves was 56% (95% confidence interval [CI]: 46% to 67%), 46% (95% CI: 31% to 61%), 8% (95% CI: 4% to 12%), and 26% (95% CI: 21% to 30%), respectively. In patients without valve failure, freedom from Fontan failure at 10 and 20 years post-Fontan palliation was 91% (95% CI: 89% to 93%) and 77% (95% CI: 73% to 81%), respectively, compared with 77% (95% CI: 69% to 85%) and 54% (95% CI: 42% to 68%), respectively, in patients with valve failure (hazard ratio: 2.43; 95% CI: 1.74 to 3.39; p < 0.001). CONCLUSIONS Atrioventricular valve failure occurs frequently in patients undergoing Fontan palliation. Patients with valve failure are twice as likely to have their Fontan circulation fail than those without valve failure.
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