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Factors influencing early and late outcome following the Fontan procedure in the current era. The 'Two Commandments'?
Eur J Cardiothorac Surg. 2007 Mar; 31(3):344-52; discussion 353.EJ

Abstract

OBJECTIVE

This study was undertaken to identify the factors affecting early and late outcome following the Fontan procedure in the current era. We have examined whether conventional selection criteria, the 'Ten Commandments', are still applicable in the current era.

MATERIALS AND METHODS

Between January 1988 and July 2004, 406 patients underwent a modified Fontan procedure at a median age of 4.7 years (IQR, 3.8-7.1 years). The single functional ventricle was of left (n=241, 59%) or right ventricular morphology (n=163, 40%). The modified Fontan procedure was performed using an atriopulmonary connection (n=162, 40%) or total cavopulmonary connection (TCPC) involving a lateral atrial tunnel (n=50, 12%) or extracardiac conduit (n=194, 48%). They were fenestrated in 216 patients (53%).

RESULTS

The early mortality was 4.4% (n=18) and four other patients required takedown of the Fontan circulation. On multivariable analysis, early outcome was adversely influenced by two factors (p<0.05): preoperative impaired ventricular function and elevated pulmonary artery pressures. Two risk models were constructed for early outcome based on preoperative and predictable operative variables (Model 1) and all preoperative and operative data (Model 2). Both models were calibrated across all deciles (p=0.83, p=0.25) and discriminated well. The area under the ROC curve was 0.85 and 0.89, respectively. There were 21 late deaths, 1 patient required late takedown of the Fontan circulation and 3 required orthotopic cardiac transplantation. Actuarial survival was 90+/-2%, 86+/-2% and 82+/-3% at 5, 10 and 15 years, respectively. Multivariable analysis identified that outcome was influenced by preoperatively impaired ventricular function, elevated preoperative pulmonary artery pressures and an earlier year of operation. The freedom from reintervention was 83+/-4%, 76+/-4% and 74+/-8% at 5, 10 and 15 years, respectively. Additional risk factors for reintervention were right atrial isomerism and preoperative small pulmonary artery size.

CONCLUSIONS

Late outcome of the Fontan circulation is encouraging. Ventricular morphology, surgical technique and fenestration do not appear to influence early or late outcome. Preoperatively impaired ventricular function and elevated pulmonary artery pressures have an adverse influence on both early and late outcome. Reintervention is common, with small preoperative pulmonary artery size being an additional risk factor.

Authors+Show Affiliations

Department of Cardiac Surgery, Birmingham Children's Hospital, United Kingdom.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

17236782

Citation

Hosein, Riad B M., et al. "Factors Influencing Early and Late Outcome Following the Fontan Procedure in the Current Era. the 'Two Commandments'?" European Journal of Cardio-thoracic Surgery : Official Journal of the European Association for Cardio-thoracic Surgery, vol. 31, no. 3, 2007, pp. 344-52; discussion 353.
Hosein RB, Clarke AJ, McGuirk SP, et al. Factors influencing early and late outcome following the Fontan procedure in the current era. The 'Two Commandments'? Eur J Cardiothorac Surg. 2007;31(3):344-52; discussion 353.
Hosein, R. B., Clarke, A. J., McGuirk, S. P., Griselli, M., Stumper, O., De Giovanni, J. V., Barron, D. J., & Brawn, W. J. (2007). Factors influencing early and late outcome following the Fontan procedure in the current era. The 'Two Commandments'? European Journal of Cardio-thoracic Surgery : Official Journal of the European Association for Cardio-thoracic Surgery, 31(3), 344-52; discussion 353.
Hosein RB, et al. Factors Influencing Early and Late Outcome Following the Fontan Procedure in the Current Era. the 'Two Commandments'. Eur J Cardiothorac Surg. 2007;31(3):344-52; discussion 353. PubMed PMID: 17236782.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Factors influencing early and late outcome following the Fontan procedure in the current era. The 'Two Commandments'? AU - Hosein,Riad B M, AU - Clarke,Andrew J B, AU - McGuirk,Simon P, AU - Griselli,Massimo, AU - Stumper,Oliver, AU - De Giovanni,Joseph V, AU - Barron,David J, AU - Brawn,William J, Y1 - 2007/01/22/ PY - 2006/08/16/received PY - 2006/11/27/revised PY - 2006/11/28/accepted PY - 2007/1/24/pubmed PY - 2007/7/12/medline PY - 2007/1/24/entrez SP - 344-52; discussion 353 JF - European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery JO - Eur J Cardiothorac Surg VL - 31 IS - 3 N2 - OBJECTIVE: This study was undertaken to identify the factors affecting early and late outcome following the Fontan procedure in the current era. We have examined whether conventional selection criteria, the 'Ten Commandments', are still applicable in the current era. MATERIALS AND METHODS: Between January 1988 and July 2004, 406 patients underwent a modified Fontan procedure at a median age of 4.7 years (IQR, 3.8-7.1 years). The single functional ventricle was of left (n=241, 59%) or right ventricular morphology (n=163, 40%). The modified Fontan procedure was performed using an atriopulmonary connection (n=162, 40%) or total cavopulmonary connection (TCPC) involving a lateral atrial tunnel (n=50, 12%) or extracardiac conduit (n=194, 48%). They were fenestrated in 216 patients (53%). RESULTS: The early mortality was 4.4% (n=18) and four other patients required takedown of the Fontan circulation. On multivariable analysis, early outcome was adversely influenced by two factors (p<0.05): preoperative impaired ventricular function and elevated pulmonary artery pressures. Two risk models were constructed for early outcome based on preoperative and predictable operative variables (Model 1) and all preoperative and operative data (Model 2). Both models were calibrated across all deciles (p=0.83, p=0.25) and discriminated well. The area under the ROC curve was 0.85 and 0.89, respectively. There were 21 late deaths, 1 patient required late takedown of the Fontan circulation and 3 required orthotopic cardiac transplantation. Actuarial survival was 90+/-2%, 86+/-2% and 82+/-3% at 5, 10 and 15 years, respectively. Multivariable analysis identified that outcome was influenced by preoperatively impaired ventricular function, elevated preoperative pulmonary artery pressures and an earlier year of operation. The freedom from reintervention was 83+/-4%, 76+/-4% and 74+/-8% at 5, 10 and 15 years, respectively. Additional risk factors for reintervention were right atrial isomerism and preoperative small pulmonary artery size. CONCLUSIONS: Late outcome of the Fontan circulation is encouraging. Ventricular morphology, surgical technique and fenestration do not appear to influence early or late outcome. Preoperatively impaired ventricular function and elevated pulmonary artery pressures have an adverse influence on both early and late outcome. Reintervention is common, with small preoperative pulmonary artery size being an additional risk factor. SN - 1010-7940 UR - https://www.unboundmedicine.com/medline/citation/17236782/Factors_influencing_early_and_late_outcome_following_the_Fontan_procedure_in_the_current_era__The_'Two_Commandments' L2 - https://academic.oup.com/ejcts/article-lookup/doi/10.1016/j.ejcts.2006.11.043 DB - PRIME DP - Unbound Medicine ER -