High-risk Fontan completion patients achieve low perioperative risk and benefit from cavopulmonary connection 7 years out†.

OBJECTIVES: Our unit has pursued Fontan completion in all patients except those with immobility or combined poor ventricular function and high pulmonary artery pressures. We assessed retrospectively whether conventional high-risk criteria would predict patients with a poorer outcome. METHODS: One hundred and thirty-three consecutive children who underwent extracardiac Fontan completion (2004-2012) had their outcomes recorded (mean follow-up of 7years). Three groups were analysed: those with 1 of 6 historical risk factors (outside 6 commandments), those with 1 of reduced systemic ventricular function or pulmonary artery pressure >15mmHg (outside 2 commandments) versus those with no contraindications. The Fischer's exact test examined frequency differences, with the chi(2) test to look for outcome associations. RESULTS: There were no differences in postoperative complication rates between the outside 6 commandments (n=105) or outside 2 commandments (n=49) versus the low-risk no-contraindication group (n=28): arrhythmias [18% (P=0.3) or 18% (P=0.3) vs 25%], infection [22% (P=0.6) or 33% (P=0.2) vs 21%], cerebrovascular accident [6% (P=0.5) or 10% (P=0.3) vs 4%], length of stay [20days (P=0.4) or 23days (P=0.2) vs 21days] and duration of chest drainage (P=0.5). There was 1 predischarge mortality in each group. Long term, the majority of patients in each group had suitable haemodynamics for fenestration closure [95% (P=0.7) or 95% (P=0.7) vs 92%]. Long term, there was no difference in the rate of arrhythmias [11% (P=0.5) or 12.5% (P=0.3) vs 7%], protein-losing enteropathy [1% (P=0.1) or 2% (P=0.3) vs 7%] or moderate or more ventricular dysfunction on echocardiography [2% (P=0.7) or 4% (P=0.7) vs 4%]. Notably, there was a higher rate of catheter reinterventions in the high-risk groups [22% (P<0.05) or 24% (P<0.05) vs 7%]. CONCLUSIONS The medium-term benefits of Fontan completion can be achieved for high-risk patients, suggesting that historical selection criteria should be re-examined.