Most long-term survivors of Fontan procedure will require reintervention

By Liz Meszaros, MDLinx
Published September 20, 2017

Key Takeaways

By 20 years, full two-thirds of patients undergoing the Fontan operation as a result of single ventricle disease in childhood may need surgical or catheter-based reintervention, according to results of a recent study published in the journal Circulation: Cardiovascular Interventions.

“Unfortunately, for many patients, the Fontan is not the final intervention,” said senior author Andrew Glatz, MD, MSCE, pediatric interventional cardiologist, Cardiac Center, Children’s Hospital of Philadelphia (CHOP), Philadelphia, PA.

The Fontan procedure is the third in a series of reconstructive operations, and although survival rates are high, normal blood circulation cannot be provided. The long-term complications of this procedure are still under investigation. Re-interventions are usually necessary in these children, but few studies have focused on quantifying the incidence.

To this end, Dr. Glatz and colleagues retrospectively reviewed 773 patients undergoing the Fontan at CHOP between 1992 and 2009, in whom 70% had current, available information regarding any post-Fontan interventions.

They found that 20 years after undergoing the Fontan procedure, a full 65% of patients had undergone either surgical or transcatheter intervention, with a median time to first re-intervention of 9.8 years.
At 15 years, 69% were free from reoperation, and at 20 years, 63%. The most common procedures included pacemaker placement and Fontan revision. The risk factors for pacemaker placement included systemic left ventricle (HR: 2.2; P=0.006), and lateral tunnel Fontan (HR: 4.3; P=0.001).

At 15 years, 53% were free from interventional catheterization, and at 20 years, 50%. The most common interventional procedures included fenestration closure and pulmonary artery intervention.

After 2002, catheter intervention for anatomic indications was associated with Fontan (HR: 2.1; P=0.007), Norwood operation (HR: 2.3; P=0.001), and longer cardiopulmonary bypass time (HR: 1.1 per 10 minutes; P=0.001).

Finally, Dr. Glatz and colleagues found that catheter intervention for physiologic indications was associated with prolonged post-Fontan pleural drainage (HR: 4.0; P < 0.001) and hypoplastic left heart syndrome (HR: 2.0; P=0.01).

“The important message from this work is that, for many patients, the Fontan operation is not the ‘final’ procedure, as it is sometimes referred to. Instead, many patients require further interventions after the Fontan to continue to try to optimize the circulation as best as possible. It’s important for families and doctors to understand this, so expectations are clear. This also highlights the need for close and careful ongoing follow-up after the Fontan operation by pediatric cardiologists familiar with potential complications that could befall a Fontan patient,” concluded Dr. Glatz.

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