What Is the Optimal Timing of Cardiac Transplantation for Failed Fontan: A Single Institution Experience
Ryan R. Davies1, Jonathan Yang1, Robert Sorabella1, Mark Russo1, Ralph S. Mosca1, Jonathan M. Chen2, Jan M. Quagebeur1; 1Columbia University Medical Center, New York, NY; 2Weill Medical College of Cornell University, New York, NY
Comment on this Abstract
Objective: An increasing number of patients are presenting with failure following the Fontan procedure. Cardiac transplantation provides one option for treating these patients, but which patients will benefit from it, and the optimal timing have not been determined. We examined our own institutional experience with transplantation for failed Fontan.
Methods: The records of 163 patients transplanted for congenital heart disease (CHD) at a single institution from 6/84-9/07 were reviewed. Of these 40 patients had a previous Fontan procedure (25m, 15f) (median age: 14.5 yrs, range: 1-47). Predictors of short- and long-term survival were evaluated and Fontan patients were compared to all other patients with CHD (n = 123: 79m, 44f) (median age: 12.8 yrs, range: 0-56).
Results: Among patients with a previous Fontan, 21 were classic Fontans, 11 were lateral tunnel, 3 had been revised back to shunts, and 1 was not specified. The most common indications for transplantation included: protein-losing enteropathy (25.9%), chronic heart failure (53.7%), and pulmonary arteriovenous malformations (7.4%). Transplants performed in Fontan patients were more likely to require pulmonary artery reconstruction (odds ratio 12.7, 95%CI 3.7-44.3) and had longer cardiopulmonary bypass times (205 vs. 280 min, p < 0.0001). Thirty-day mortality was higher in the Fontan group (25.0% vs. 13.0%) (2.2, 0.9-5.4), but among patients surviving 30-days, long-term outcomes were similar (p=0.7581) (1-yr: 83.2% vs 90.3%, 5-yr: 78.3% vs. 82.1%, 10-yr: 69.6% vs. 64.4%, p = 0.7581).
Within the Fontan group no correlation between the time from Fontan to transplantation and mortality was observed. Predictors of 30-day mortality within the Fontan group are shown in the table. Renal failure was a strong predictor of early mortality (10.8, 1.5-75.7).
Conclusion: Transplantation is an acceptable treatment for patients with a failed Fontan. Clinical factors (rather than the indication for transplantation) appear to have the highest correlation with early mortality. This suggests that patients with failed Fontans should be transplanted prior to the onset of renal failure or the need for additional physiologic support (mechanical ventilation or circulatory support).
Risk Factors for 30-day Mortality Among Failed Fontan Patients
| Risk Factor | Mortality | Odds Ratio (95%CI) |
| Creatinine > 1.5 | 4/6 (66.7%) | 10.8 (1.5-75.7) |
| Extracorporeal membrane oxygenation | 3/5 (60.0%) | 5.6 (0.8-40.1) |
| Mechanical ventilation | 3/7 (42.9%) | 5.0 (0.7-34.3) |
| Less than 30-days since Fontan | 2/4 (50.0%) | 4.0 (0.5-34.5) |
| Age > 18 years | 5/13 (38.5%) | 2.8 (0.6-12.1) |
Back to 88th Annual Meeting
Back to Program Outline
