Evolution of the Fontan procedure in a single center

Background. Surgical approaches to single ventricle variants include staged , fenestrated, and completed Fontan operations. This study compares outcome s with these modifications of the Fontan operation at a single center. Methods. Preoperative risk factors and operative results were analyzed by m ultivariate techniques in 129 patients undergoing modified Fontan operation s since March 1988. Results. Overall early and late mortality was 5.4% and 0.8%, respectively. Before 1993, completed Fontan operation using right atrial to pulmonary art ery anastomosis without fenestration was performed in the majority of patie nts (44 of 58; 76%). During this period, 10 of 17 patients at high risk had completed Fontan with three takedowns. In 1994, the staged hemi-Fontan and modified Fontan with a lateral tunnel anastomosis and with or without smal l fenestration (2.5 to 4 mm) were introduced. The majority of patients at h igh risk during this period underwent hemi-Fontan followed by fenestrated F ontan with no takedowns. Late atrial dysrhythmias occurred in 6 patients (4 .7%), generally with larger fenestrations or right atrial to pulmonary anas tomoses. Three patients (2.3%) had a stroke, 2 with large (greater than or equal to 4 mm) fenestrations. Of 38 fenestrations, 32 (84%) closed spontane ously by 1 year. No protein-losing enteropathy occurred. Most patients (118 of 121) were in New York Heart Association class I/II 4.5 years postoperat ively. By multivariate analysis, only Down's syndrome (p < 0.001) predicted early mortality, whereas both Down's syndrome and a systemic right ventric le decreased late survival (p < 0.006). Conclusions. Proper selection of patients for modifications of the Fontan p rocedure resulted in excellent early and late survival with a low incidence of atrial dysrhythmia and stroke. Midterm functional outcomes were excelle nt. (C) 2000 by The Society of Thoracic Surgeons.