The Evolving Surgical Burden of Fontan Failure: Insights from a Nationwide Surgical Database.
BACKGROUND: Fontan failure often requires surgical therapy in the form of Fontan revision or heart transplantation. We sought to characterize national trends in the surgical burden of Fontan failure and identify risk factors for adverse outcomes. METHODS: Fontan patients undergoing Fontan revision or transplant from 1/2010-6/2018 were included. We evaluated baseline characteristics and outcomes and used multivariable logistic regression to identify risk factors for operative mortality and composite mortality/major morbidity. RESULTS: 1135 patients underwent Fontan revision (n=598) or transplant (n=537) at 100 centers. Transplants increased from 34 in 2010 to 76 in 2017, largely due to increase in patients with hypoplastic left heart syndrome (HLHS, 18 in 2010 to 49 in 2017), while Fontan revision decreased (75 in 2010 to 49 in 2017). Transplant patients were younger (median 14yrs vs 18yrs, p< 0.0001), more often had preoperative risk factors (66% vs. 40%, p<0.0001), and more often had HLHS (51% vs 15%, p< 0.0001). Operative mortality and composite major morbidity/mortality were 7.6% and 35% for transplant and 7.1% and 22% for Fontan revision. Multivariable risk factors for mortality included older age (OR 1.08/year, p=0.0065), presence of preoperative risk factors (OR 3.33, p=0.0022), and concomitant pulmonary artery reconstruction (OR 2.7, p=0.0288) for Fontan revision but only older age (OR 1.06/year, p=0.0199) for transplant. CONCLUSIONS: Both transplantation and Fontan revision are associated with high morbidity and mortality. There has been evolution of practices in surgical therapy for Fontan failure, perhaps related to rising prevalence of HLHS staged palliation.
Serfas, JD; Thibault, D; Andersen, ND; Chiswell, K; Jacobs, JP; Jacobs, ML; Krasuski, RA; Lodge, AJ; Turek, JW; Hill, KD
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