Ten-year outcomes of Fontan conversion in Australia and New Zealand demonstrate the superiority of a strategy of early conversion

Chin Leng Poh; Andrew Cochrane; John C Galati; Andrew Bullock; David S Celermajer; Tom Gentles; Karin du Plessis; David S Winlaw; Tim Hornung; Kirsten Finucane; Yves d'Udekem

doi:10.1093/ejcts/ezv112

Ten-year outcomes of Fontan conversion in Australia and New Zealand demonstrate the superiority of a strategy of early conversion

Eur J Cardiothorac Surg. 2016 Feb;49(2):530-5; discussion 535. doi: 10.1093/ejcts/ezv112. Epub 2015 Apr 2.

Authors

Affiliations

¹ Murdoch Children's Research Institute, Melbourne, VIC, Australia Department of Paediatrics, Faculty of Medicine, University of Melbourne, Melbourne, VIC, Australia.
² Department of Cardiothoracic Surgery, Monash Medical Centre, Monash University Faculty of Medicine, Melbourne, VIC, Australia.
³ Murdoch Children's Research Institute, Melbourne, VIC, Australia Department of Mathematics and Statistics, La Trobe University, Melbourne, VIC, Australia.
⁴ Children's Cardiac Centre, Princess Margaret Hospital for Children, Perth, WA, Australia.
⁵ Department of Medicine, The University of Sydney, Sydney, NSW, Australia Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
⁶ Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital Auckland, Auckland, New Zealand.
⁷ Murdoch Children's Research Institute, Melbourne, VIC, Australia.
⁸ Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia.
⁹ Murdoch Children's Research Institute, Melbourne, VIC, Australia Department of Paediatrics, Faculty of Medicine, University of Melbourne, Melbourne, VIC, Australia The Royal Children's Hospital, Melbourne, VIC, Australia yves.dudekem@rch.org.au.

PMID: 25838458
DOI: 10.1093/ejcts/ezv112

Abstract

Objective: To investigate the benefits of a strategy of early Fontan conversion.

Methods: Using the Australia and New Zealand Fontan Registry, retrospective analysis of their long-term follow-up data was performed.

Results: Between 1990 and 2014, a total of 39 patients underwent surgical conversion in 6 centres at a median age of 23.8 years (IQR: 19.3-28.2), 18.7 ± 5.0 years post-Fontan. One centre tended to perform conversion earlier: interval since first documented arrhythmia 2.9 ± 4.0 vs 4.0 ± 4.2 years, average NYHA Class 2 ± 0.4 vs 3 ± 0.9 (P = 0.008), mean number of preop anti-arrhythmics 1 ± 0.4 vs 2 ± 0.6 (P = 0.05). Two patients underwent conversion to an extracardiac conduit only, while 36 had concomitant right atrial cryoablation, of which 16 also had pacemaker implantation. Nine patients suffered major cardiac-related complications (7 low output syndrome, 3 ECMO, 3 acute renal failure, one stroke) (2/17 from the early conversion centre and 7/22 of the others; P = 0.14). Four patients died in hospital (10.3%) and 4 late after a median of 0.9 years [95% confidence interval (CI): 0.5-1] after conversion. An additional 2 patients needed transplantation at 1 and 8.8 years after conversion, respectively. The 10-year freedom from heart transplantation was 86% (95% CI: 51-97%). Outcomes from the centre with an early conversion strategy were significantly better: 8-year freedom from death or heart transplantation was 86% (95% CI: 53-96) vs 51% (95% CI: 22-74; log-rank P = 0.007). Eight additional patients required pacemaker implantation and 5 had arrhythmia recurrence.

Conclusions: Fontan conversion is associated with lasting survival outcomes up to 10 years after conversion. A strategy of surgical conversion at earlier stage of failure may be associated with better survival free from transplantation.

Keywords: Atriopulmonary Fontan; Fontan conversion; Fontan procedure; Long-term outcomes.

Publication types

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

MeSH terms

Adolescent
Adult
Australia
Female
Follow-Up Studies
Fontan Procedure*
Heart Transplantation / statistics & numerical data
Humans
Kaplan-Meier Estimate
Male
New Zealand
Outcome Assessment, Health Care
Postoperative Complications / epidemiology
Registries
Reoperation / methods*
Reoperation / mortality
Retrospective Studies
Young Adult