Lateral tunnel Fontan in the current era: is it still a good option?

Background: Construction of a total cavopulmonary anastomosis using an intra-atrial lateral tunnel Fontan (LTF) is known to yield good early and midterm results. Given the current controversy regarding indications for a total extracardiac conduit Fontan, we reviewed the long-term outcomes after a LTF operation and compared them with recently published series using one or both techniques.

Methods: Between 1992 and 2008, 220 of 280 patients (median age, 2.5 years; range, 1 to 45) with a wide range of underlying diagnoses underwent a fenestrated or nonfenestrated LTF operation at our institution. Current follow-up information was available for 215 patients (98%; mean follow-up, 6.7 +/- 3.9 years). Risk factor analysis included patient-related and procedure-related variables, with death, failure (takedown or transplantation), and bradyarrhythmia or tachyarrhythmia as outcome variables.

Results: There was 1 early death, 10 late deaths, 3 takedown operations, and 1 heart transplantation. Kaplan-Meier estimated survival was 96% at 5 years and 95% at 10 and 15 years, and freedom from failure was 94% at 5 years and 93% at 10 years. Freedom from new supraventricular tachyarrhythmia was 98% at 5 years and 95% at 10 years; freedom from new bradyarrhythmia was 97% at 5 years and 96% at 10 years. Six patients have protein-losing enteropathy, and 2 of 6 have had Fontan takedown. Multivariable risk factors for development of supraventricular tachyarrhythmia included atrioventricular valve abnormalities (p = 0.02), and preoperative bradyarrhythmia (p = 0.01). Risk factors for bradyarrhythmia included the need for early postoperative pacing (p = 0.001). None of the patient-related variables significantly influenced survival.

Conclusions: The LTF operation results in excellent midterm outcome even when used in patients with complex anatomy. The incidence of postoperative atrial tachyarrhythmia is low and depends largely on the underlying cardiac morphology and incidence of preoperative arrhythmia. The good midterm outcome after a LTF operation should serve as a basis for comparison with other surgical alternatives to complete the Fontan circulation.