Outcomes of the Surgical Management of Atrial Isomerism and Functional Single Ventricle: A Single-Centered Cohort From China

Impact of cardiac position, morphology and operative technique on long-term Fontan outcomes in heterotaxy†

OBJECTIVES

This study aimed to assess the outcomes of heterotaxy patients who underwent the Fontan operation, focusing on morphological features and surgical techniques.

METHODS

Eighty-two consecutive heterotaxy patients who underwent the Fontan operation from 1985 to 2021 were compared to 150 patients with tricuspid atresia (TA) and 144 patients with hypoplastic left heart syndrome (HLHS). The Kaplan-Meier method and Cox proportional hazard model were used to analyse transplant-free survival and predictor of outcomes.

RESULTS

The 20-year transplant-free survival rates were comparable between right atrial isomerism (RAI, n = 45) and left atrial isomerism (LAI, n = 37) [RAI versus LAI, 76% (95% confidence interval, 57-87%) vs 68% (47-82%), P = 0.22], although more pulmonary vein interventions at Fontan were needed in RAI. Surgical techniques included extracardiac conduit in 66%, intra-atrial conduit in 9% and lateral tunnel in 18% of the cases. Cardiac position and apicocaval juxtaposition did not influence outcomes, but the inferior vena cava (IVC)-contralateral pulmonary artery (PA) Fontan was associated with 100% survival, while the IVC-ipsilateral PA Fontan at the cardiac apex showed a 67% (34-87%) survival rate at 20 years. In-hospital mortality was higher in heterotaxy [9.8% (5-19%)] compared to TA [1.3% (0.3-5.3%), P<0.01) and HLHS [2.8% (1.1-7.3%), P = 0.02], with no early death after 2000 in any group. The 20-year transplant-free survival in heterotaxy [72% (59-82%)] was similar to that in HLHS [80% (69-87%), P = 0.11].

CONCLUSIONS

Various routing techniques can be successfully applied to overcome anatomical challenges in heterotaxy. Despite higher in-hospital mortality, overall survival was similar to HLHS. RAI had comparable survival to LAI with more pulmonary vein interventions at Fontan.

The Clinical Outcomes in Patients With Atrial Isomerism Undergoing Single Ventricular Palliation: Insights From A Single-Center Study in Thailand

Background: The management of atrial isomerism across various countries may impact survival outcomes. Methods: This retrospective study involved patients diagnosed with atrial isomerism undergoing single ventricular palliation between 2000 and 2021. The objective was to evaluate survival outcomes within the right atrial isomerism (RAI) and left atrial isomerism (LAI) groups, as well as overall survival. Results: Of the 125 patients diagnosed with atrial isomerism, 105 (84%) had RAI, and 20 (16%) had LAI. The median age at presentation was 3 days (range: birth to 7.1 years), with median follow-up of 6.6 years (range: 0.59 months to 30.8 years). In the overall cohort, survival rates at one, five, and ten years were 85.6%, 72.3%, and 66.8%, respectively, with no statistically significant difference between RAI and LAI groups (log rank P value = .293). Specifically, survival rates in the RAI group at one, five, and ten years were 83.8%, 69.0%, and 62.6%, respectively, while in the LAI group, there were 95.0%, 89.7%, and 81.6%, respectively. Following the third-stage operation, overall survival rates at one and five years were 76.4% and 76.4%, respectively. Among patients in the RAI group, survival rates at one and five years post-third stage operation were 80.2% and 80.2%, respectively. Conclusions: Despite resource limitations, the survival outcomes of patients with atrial isomerism were found to be similar with those observed in high-income countries. Although an increased mortality rate was noted within the first year of life, focusing efforts on neonatal and infant care holds potential for improving overall outcomes.

National outcomes of the Fontan operation with endocardial cushion defect

BACKGROUND

The traditional outcomes of the Fontan operation (FO) in endocardial cushion defect (ECD) patients have been suboptimal. Previous studies have been limited by the smaller number of ECD patients, longer study period with an era effect, and do not directly compare short-term outcomes of FO in ECD patients with non-ECD patients. Our study aims to address these shortcomings.

METHODS

A retrospective analysis of the Kids Inpatient Database (2009, 2012, and 2016) for the FO was done. The groups were divided into those who underwent FO with ECD as compared to non-ECD diagnosis. The data were abstracted for demographics, clinical characteristics, and operative outcomes. Standard statistical tests were used.

RESULTS

Three thousand three hundred eighty patients underwent the FO of which 360 patients (11%) were FO-ECD. ECD patients were more likely to have Down syndrome, Heterotaxy syndrome, transposition/DORV, and TAPVR as compared to non-ECD patients. FO-ECD had a higher discharge-mortality (2.84% vs. 0.45%, p = .04). The length of stay (16 vs. 13 days, p = .05) and total charges incurred ($283, 280 vs. $234, 106, p = .03) for the admission were higher in the FO-ECD as compared to non-ECD patients. In multivariable analysis, ECD diagnosis, cardiac arrest, acute kidney injury, and postoperative hemorrhage were predictors of mortality.

CONCLUSION

Contemporary outcomes for FO are excellent with very low overall operative mortality. However, the outcomes in ECD patients are inferior with higher operative mortality than in non-ECD patients. The occurrence of postoperation complications and a diagnosis of ECD were predictive of a negative outcome.