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Biventricular conversion after Fontan completion: A preliminary experience

      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

      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)
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