Abstract
Objective
To assess the feasibility and outcomes of biventricular conversion following takedown
of Fontan circulation.
Methods
Retrospective analysis of patients who had takedown of Fontan circulation and conversion
to biventricular circulation at a single center from September 2007 to April 2020.
Failing Fontan physiology was defined as Fontan circulation pressure >15 mm Hg and/or
the presence of associated complications.
Results
Biventricular conversion was performed in 23 patients at a median age of 10.0 (7.5-13.0)
years. Indications included failing Fontan physiology in 15 (65%) and elective takedown
in 8 (35%) patients. A subset of patients (n = 6) underwent procedures for staged
recruitment of the nondominant ventricle before conversion. Median z score of end-diastolic
volume of borderline ventricle before takedown was –2.3 (–3.3, –1.3). Hypoplastic
left heart syndrome (P < .01) and sub-/aortic stenosis (P < .01) were more common in these patients. Biventricular conversion with or without
staged ventricular recruitment led to a significant increase in indexed end-diastolic
volume (P < .01), indexed end-systolic volume (P < .01), and ventricular mass (P < .01) of the nondominant ventricle (14 right, 9 left ventricle). There were 5 (22%)
deaths (1 [4%] early death). All who underwent elective biventricular conversion survived,
whereas 2-year survival rate for patients with a failing Fontan circulation was 72.7%
(95% confidence interval, 37%-90%). The overall, 3-year reoperation-free survival
was 86.7% (95% confidence interval, 56%-96%). Left dominant atrioventricular canal
defect (P < .01) and early era of biventricular conversion (P = .02) were significant predictors for mortality.
Conclusions
A primary as well as a staged biventricular conversion is feasible in patients who
have had previous Fontan procedure. Although this provides an alternative to transplantation
in patients with failing Fontan, outcomes are worse in those with failing Fontan compared
with elective takedown of Fontan circulation. Optimal timing needs further evaluation.
Graphical abstract
Graphical Abstract
Key Words
Abbreviations and Acronyms:
AVCD (atrioventricular canal defects), BCH (Boston Children's Hospital), BiV (biventricular), BiVC (biventricular conversion), CI (confidence interval), CMR (cardiovascular magnetic resonance), EDP (end-diastolic pressure), EDV (end-diastolic volume), ESV (end-systolic volume), IQR (interquartile range), LV (left ventricle), LVOT (left ventricular outflow tract), MV (mitral valve), P-BiVC (primary biventricular conversion), RV (right ventricle), S-BiVC (staged biventricular conversion), SVP (single-ventricle physiology), TGA (transposition of the great arteries)To read this article in full you will need to make a payment
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References
- 40-year follow-up after the fontan operation long-term outcomes of 1,052 patients.J Am Coll Cardiol. 2015; 66: 1700-1710
- Clinical outcomes in adolescents and adults after the fontan procedure.J Am Coll Cardiol. 2018; 71: 1009-1017
- Staged left ventricular recruitment after single-ventricle palliation in patients with borderline left heart hypoplasia.J Am Coll Cardiol. 2012; 60: 1966-1974
- Hemodynamic parameters predict adverse outcomes following biventricular conversion with single-ventricle palliation takedown.J Thorac Cardiovasc Surg. 2017; 154: 572-582
- Clinical and hemodynamic results after conversion from single to biventricular circulation after fetal aortic stenosis intervention.Am J Cardiol. 2018; 122: 511-516
- Staged ventricular recruitment in patients with borderline ventricles and large ventricular septal defects.J Thorac Cardiovasc Surg. 2018; 156: 254-264
- Biventricular conversion after single-ventricle palliation in unbalanced atrioventricular canal defects.Ann Thorac Surg. 2013; 95: 2086-2096
- Biventricular conversion after single ventricle palliation in patients with small left heart structures: short-term outcomes.Ann Thorac Surg. 2013; 96: 1406-1412
- Strategies to maintain biventricular circulation in patients with high-risk anatomy.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2013; 16: 37-42
- Takedown of cavopulmonary shunt at biventricular repair.J Thorac Cardiovasc Surg. 2014; 148: 1506-1511
- Operations for improving left ventricular diastolic function.Curr Opin Cardiol. 2016; 31: 101-108
- Neonatal mitral valve repair in biventricular repair, single ventricle palliation, and secondary left ventricular recruitment: indications, techniques, and mid-term outcomes.Front Surg. 2015; 2: 59
- Diagnosis and management of the adult patient with a failing Fontan circulation.Heart Fail Rev. 2020; 25: 633-646
- The relentless effects of the Fontan paradox.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2016; 19: 37-43
- Heart transplantation in Fontan patients across Australia and New Zealand.Heart. 2016; 102: 1120-1126
- Heart transplantation and in-hospital outcomes in adult congenital heart disease patients with Fontan: a decade nationwide analysis from 2004 to 2014.J Card Surg. 2020; 35: 603-608
- Two ventricles are not better than one in the Fontan circulation: equivalent late outcomes.Ann Thorac Surg. 2019; 107: 852-859
- Modes of late mortality in patients with a Fontan circulation.Heart. 2020; 106: 1427-1431
- Surgical options after Fontan failure.Heart. 2016; 102: 1127-1133
- Clinical outcome of the Fontan operation in patients with impaired ventricular function.Eur J Cardiothorac Surg. 2009; 36: 683-687
- Outcome after Fontan failure and takedown to an intermediate palliative circulation.Ann Thorac Surg. 2007; 84: 880-887
- The registry report of heart transplantation in Japan (1999-2014).Circ J. 2015; 80: 44-50
- Cardiovascular magnetic resonance parameters associated with early transplant-free survival in children with small left hearts following conversion from a univentricular to biventricular circulation.J Cardiovasc Magn Reson. 2014; 16
Article info
Publication history
Published online: May 03, 2021
Accepted:
April 17,
2021
Received in revised form:
March 23,
2021
Received:
October 14,
2020
Identification
Copyright
© 2021 by The American Association for Thoracic Surgery
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Access this article on ScienceDirectLinked Article
- Commentary: Biventricular conversion after Fontan completion—what have we learned so far?The Journal of Thoracic and Cardiovascular SurgeryVol. 163Issue 3
- PreviewThere are many questions in congenital heart surgery that remain unanswered. Whether a biventricular repair is necessarily better than a univentricular repair is one question that is particularly difficult to know. The true benefits of a biventricular repair may only be realized after many years, and no realistic control group exists for a definitive trial to examine this topic. In this issue of the Journal, Doulamis and colleagues1 attempt to tackle this question and present their preliminary Boston experience with biventricular conversion after Fontan completion.
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- Commentary: Time for a new maximThe Journal of Thoracic and Cardiovascular SurgeryVol. 163Issue 3
- Commentary: Biventricular conversion: A decade of data delivers more debateThe Journal of Thoracic and Cardiovascular SurgeryVol. 163Issue 3
- PreviewDoulamis and colleagues1 report a retrospective report of 23 patients who underwent biventricular conversion (BiVC) following Fontan completion at their center over a 13-year period. This report builds on previously published excellent data from this center, and is an important contribution to our collective understanding regarding the selection and management of these challenging patients.
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