TY - JOUR
T1 - Long-term survival after the Fontan operation
T2 - Twenty years of experience at a single center
AU - Downing, Tacy E.
AU - Allen, Kiona Y.
AU - Glatz, Andrew C.
AU - Rogers, Lindsay S.
AU - Ravishankar, Chitra
AU - Rychik, Jack
AU - Faerber, Jennifer A.
AU - Fuller, Stephanie
AU - Montenegro, Lisa M.
AU - Steven, James M.
AU - Spray, Thomas L.
AU - Nicolson, Susan C.
AU - Gaynor, J. William
AU - Goldberg, David J.
N1 - Publisher Copyright:
© 2017 The American Association for Thoracic Surgery
PY - 2017/7
Y1 - 2017/7
N2 - Objective Existing studies of patients palliated with the Fontan operation are limited by heterogeneous patient populations and incomplete follow-up. This study aimed to describe long-term post-Fontan survival in a modern patient cohort. Methods All 773 patients who underwent a first Fontan operation at our institution between 1992 and 2009 were reviewed. The primary outcome was the composite endpoint of Fontan takedown, heart transplantation, or death before 2013. Results Follow-up rate was 99.2%. Survival with intact Fontan circulation was 94% at 1 year (95% confidence interval [95% CI], 92%-95%), 90% at 10 years (95% CI, 88%-92%), 85% at 15 years (95% CI, 82%-88%), and 74% at 20 years (95% CI, 67%-80%). Distinct risk factors were identified for early (≤1 year) and late composite outcomes. Independent risk factors for early outcome included prolonged pleural drainage (hazard ratio [HR], 4.4; P <.001), intensive care unit stay >1 week (HR, 2.4; P <.001), Fontan before 1997 (HR, 3.3; P <.001), preoperative atrioventricular valve regurgitation (HR, 2.0; P <.001), and longer crossclamp time (HR, 1.3 per 10 minutes; P <.001). Late outcome was predicted by atrioventricular valve regurgitation prior to Fontan (HR, 2.0; P ≤.001), and post-Fontan ICU stay >1 week (HR, 2.4; P <.001). Conclusions Long-term mortality after Fontan operation remains substantial. Risk factors for death or loss of Fontan circulation differ between the early and late postoperative periods. Long-term survival has not improved appreciably over the last decade, suggesting that alternatives to the Fontan are warranted.
AB - Objective Existing studies of patients palliated with the Fontan operation are limited by heterogeneous patient populations and incomplete follow-up. This study aimed to describe long-term post-Fontan survival in a modern patient cohort. Methods All 773 patients who underwent a first Fontan operation at our institution between 1992 and 2009 were reviewed. The primary outcome was the composite endpoint of Fontan takedown, heart transplantation, or death before 2013. Results Follow-up rate was 99.2%. Survival with intact Fontan circulation was 94% at 1 year (95% confidence interval [95% CI], 92%-95%), 90% at 10 years (95% CI, 88%-92%), 85% at 15 years (95% CI, 82%-88%), and 74% at 20 years (95% CI, 67%-80%). Distinct risk factors were identified for early (≤1 year) and late composite outcomes. Independent risk factors for early outcome included prolonged pleural drainage (hazard ratio [HR], 4.4; P <.001), intensive care unit stay >1 week (HR, 2.4; P <.001), Fontan before 1997 (HR, 3.3; P <.001), preoperative atrioventricular valve regurgitation (HR, 2.0; P <.001), and longer crossclamp time (HR, 1.3 per 10 minutes; P <.001). Late outcome was predicted by atrioventricular valve regurgitation prior to Fontan (HR, 2.0; P ≤.001), and post-Fontan ICU stay >1 week (HR, 2.4; P <.001). Conclusions Long-term mortality after Fontan operation remains substantial. Risk factors for death or loss of Fontan circulation differ between the early and late postoperative periods. Long-term survival has not improved appreciably over the last decade, suggesting that alternatives to the Fontan are warranted.
KW - cardiovascular surgery
KW - congenital heart disease
KW - mortality/survival
KW - transplantation
UR - http://www.scopus.com/inward/record.url?scp=85015804827&partnerID=8YFLogxK
U2 - 10.1016/j.jtcvs.2017.01.056
DO - 10.1016/j.jtcvs.2017.01.056
M3 - Article
C2 - 28341469
AN - SCOPUS:85015804827
SN - 0022-5223
VL - 154
SP - 243-253.e2
JO - Journal of Thoracic and Cardiovascular Surgery
JF - Journal of Thoracic and Cardiovascular Surgery
IS - 1
ER -